Canadian psychiatry across 5 decades: from clinical inference to evidence-based practice

Non-strategic ignorance: Considering the potential for a paradigm shift in evidence-based mental health

Randomised controlled trials form a central building block within the prevailing evidence-based mental health paradigm. Both methodology and paradigm have been widely problematised since their emergence in the mid-late twentieth century. We draw on the concept of ‘strategic ignorance’ to understand why the paradigm still prevails. We present focus group data gathered from 37 participants (service users, public, carers, general practitioners, commissioners) concerning the way they made sense of a randomised controlled trial of psychotherapy for treatment-resistant depression. Thematic analysis of the findings revealed an overall critique of randomised controlled trial methods which we refer to as ‘non-strategic ignorance’. Specifically, participants problematised the construct of depression, unseating the premise of the randomised controlled trial; they were sceptical about the purpose and highlighted its failure to show how therapy works or who might benefit; the randomised controlled trial was seen as inadequate for informing decisions about how to select a therapy. Participants assumed the treatment would be cost-effective given the client group and nature of the therapy, irrespective of any randomised controlled trial findings. Each area of lay (‘non-strategic’) critique has an analogous form within the methodological expert domain. We argue that ‘expert’ critiques have generally failed to have paradigmatic impact because they represent strategic ignorance. Yet parallel non-strategic critiques have common sense appeal, highlighting the potential power of lay voices. The discussion considers whether the evidence-based mental health paradigm is faced with epistemological problems of such complexity that the conditions exist for a new paradigm in which service user views are central and randomised controlled trials peripheral.

Canadian psychiatry: a status report

The delivery of health care in Canada is shaped by a number of variables – geography, legislation, federal structure, location and culture.

Quality assessment of observational studies in psychiatry: an example from perinatal psychiatric research

In perinatal psychiatry, randomized controlled trials are often not feasible on ethical grounds. Many studies are observational in nature, while others employ large databases not designed primarily for research purposes. Quality assessment of the resulting research is complicated by a lack of standardized tools specifically for this purpose. The aim of this paper is to describe the Systematic Assessment of Quality in Observational Research (SAQOR), a quality assessment tool our team devised for a series of systematic reviews and meta-analyses of evidence-based literature regarding risks and benefits of antidepressant medication during pregnancy.

Entangled Matters--Alzheimer's, interiority, and the 'unflattening' of the world

When, in the 1980s, Alzheimer's disease became a disease of major public concern, 'personhood' also became an important, related topic of discussion. Those in caring professions (psychology, social work, etc.) and caregiver groups advocated for the 'person within' who was getting lost in a forgetful body and in a reductionist biomedical system. This essay aims to critically approach the dualism of this kind of argument by focusing on the moral positioning of claims such as personhood or biomedical reductionism.

Mental health reform and evolution of general psychiatry in Ontario

OBJECTIVES

To discuss developments in Ontario mental health reform, describe general psychiatric services in contrast to tertiary services, describe guidelines for the training of general psychiatrists, and suggest what changes may be required to develop an integrated mental health system (IMHS).

METHOD

We review the Ontario government's recent blueprint for mental health reform and the Canadian federal government's document on best practices in psychiatry, in the context of defining general psychiatric services and their relation to tertiary services. From this, we consider the education of general psychiatrists and make suggestions for their training.

RESULTS

General psychiatric services correspond to first-line and intensive psychiatric services delivered by community mental health agencies, community psychiatrists, and general hospitals for patients with moderate or serious mental illness. Many suggest that psychiatrists are not being trained to meet the needs of a reformed mental health system. An education program for general psychiatrists should include training in a wide range of community and general hospital settings, work within a multidisciplinary mental health team, and experience working in a shared care model with family physicians.

CONCLUSIONS

Along with training general psychiatrists better, we must also develop recruitment and payment incentives, which would allow general psychiatrists who are based in the community and general hospitals to work within an IMHS.

Academic and research interest in several approaches to psychotherapy: a computerized search of literature in the past 16 years

A computerized search of published abstracts in PsychInfo was conducted to obtain the frequency of annual citations since 1984 for six forms of psychotherapy. Cognitive-Behavioral therapies showed the most rapid increase over the past 16 years. Family therapies, in contrast, showed a significant decline in the number of abstract citations since 1990. At present, brief, empirically tested treatments appear to be generating the greatest discussion in the academic and scientific literature.