Closing the gap between research and practice

Review: Recommendations for male-friendly counselling with adolescent males: A qualitative systematic literature review

BACKGROUND

There are growing calls to tailor counselling practices for adolescent males, a population reluctant to engage in psychological treatment despite concerning rates of mental illness. The objective of this systematic review (PROSPERO: CRD4202125547) was to collate and synthesise recommendations for individual counselling with adolescent males (12-18 years).

METHOD

The databases Psychology and Behavioural Science Collection, PsycArticles, PsycINFO, Academic Search Complete, EBSCO eBook Collection, Wiley Science Collection, Taylor and Francis Collection and ProQuest One Academic were searched for articles published between 1995 and November 2021. The quality of evidence was assessed using the JBI critical appraisal checklists, and thematic analysis was employed to synthesise findings across the literature.

RESULTS

A total of 1625 texts were identified, of which 16 met the inclusion criteria. Generated themes included (a) therapist knowledge of masculinity, gender socialisation, and male-relational styles; (b) necessity of therapists to address masculinity in the therapeutic space; and (c) customising engagement and treatment practices to appeal to adolescent males.

CONCLUSIONS

The themes highlighted the unique developmental, and sociocultural considerations practitioners should be aware of when working with young men. Through a multicultural counselling competency framework, masculinity and adolescent male identity are expressions of diverse sociocultural identities that psychological assessment and intervention should ideally be tailored to suit. The findings of the review suggest that empirical research focusing on the experiences of adolescent males receiving psychological treatment is sparse. Further research is needed to inform the development of practicable, gender-sensitive adaptions to counselling practice for young men.

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.

Lost in translation: transferring knowledge from research to clinical practice

Using a new treatment is not an instantaneous act. There is a gap between research and practice and carefully evaluated evidence often fails to achieve widespread use. Various factors intercede along the pathway from knowledge generation to knowledge utilisation. These can hinder, or indeed facilitate, the use of research evidence in psychiatry. Knowledge translation is a discipline that attempts to identify and understand these barriers and facilitators to knowledge transfer. In this article, the terminology and key concepts of knowledge translation will be outlined, the evidence transfer pipeline described and obstacles and facilitators to uptake of evidence explored. The article also identifies sources of information on knowledge transfer. Innovative approaches designed to enhance the uptake of evidence from research, such as summaries, systematic reviews and targeted messaging, are also described.

How to appraise an article on therapy

This first of a series of articles intended to guide clinicians through the evidence-based process assesses the published evidence for drug therapy in Alzheimer's disease. A Medline search identified a randomised, controlled trial of donepezil. Although this trial appeared to have a reasonably sound methodology, we had some doubts about the treatment effect and applicability of the results.

Psychiatrists' views of evidence-based psychiatric practice

Aims and method

To determine the attitudes of psychiatrists towards the practice of evidence-based medicine by use of a postal questionnaire. A survey was sent to Consultant Psychiatrists and to Higher Trainees in Psychiatry in the West of Scotland Region.

Results

While older influences on decision-making such as tradition and deference still play a part, almost all respondents consider the adoption of more effective care based on best available external evidence desirable; most think it attainable. The technology is generally available, but further training is desired to access the information and its critical analysis.

Clinical implications

Educational activities should increasingly focus on skills for data search and critical analysis.

Evaluating qualitative papers in a multidisciplinary evidence-based journal club: a pilot study

Journal clubs have traditionally been important means by which clinicians, academics and trainees appraise research that relates to their field. In recent years the evidence-based style has become more prevalent, allowing knowledge gleaned from research to be applied to clinical situations. Currently, the main approach of evidence-based journal clubs is quantitative. This paper describes the evaluation of a modified journal club format, developed in an academic department of a medical school and combining the appraisal of both qualitative and quantitative papers.

[Arts therapies in severe mental illness: are they effective?]

Arts therapies are widely used treatment strategies for people with severe mental illness. Generally, only a few randomized trials are available, however, the studies show that additional use of arts therapies reduces the appearance of negative symptoms among people with schizophrenia. The most significant evidence can be seen with music therapy. The treatment of severe depression has shown that additional music therapy improves depression. The S3 guidelines on psychosocial therapies in severe mental illness of the Germany Society for Psychiatry, Psychotherapy and Neurology (DGPPN) recommended arts therapies are with recommendation level B.

The contribution of advisory committees and public involvement to large studies: case study

BACKGROUND

Many large studies have complex advisory committee structures, yet there is no empirical evidence regarding their optimal composition, scope and contribution. The aim of this study was to inform the committee and advice infrastructure for future research studies.

METHODS

In the context of a five-year study funded by the UK National Institute for Health Research, three advisory committees were formed. In addition, advice was obtained from individual experts. All recommendations received in the start-up phase (first seven months) of the study were recorded, along with the decision about implementation of the recommendation. A particular focus was on the impact of public involvement.

RESULTS

A total of 172 recommendations were made, including 70 from 20 individual experts. The recommendations were grouped into five emergent themes: Scientific, Pragmatic, Resources, Committee and Collaboration. Most recommendations related to strengthening existing components or adding new components to the study protocol. Very few recommendations either proposed removing study components or contradicted other recommendations. Three 'implementation criteria' were identified: scientific value, pragmatic feasibility, and paradigmatic consistency. 103 (60%) of recommendations were implemented and 25 (15%) were not implemented. The benefits identified by the research team were improved quality and confidence, and the costs were increased cognitive demands, protocol revision time, and slower progress.

CONCLUSIONS

The findings are discussed in the context of the wider literature on public involvement in research. Six recommendations are identified. First, have a clear rationale for each advisory committee expressed as terms of reference, and consider the best balance between committees and individual consultation with experts. Second, an early concern of committees is inter-committee communication, so consider cross-representation and copying minutes between committees. Third, match the scope of advisory committees to the study, with a less complex advisory structure for studies with more finalised designs. Fourth, public involvement has a mixed impact, and relies on relationships of trust, which take time to develop. Fifth, carefully consider the match between the scientific paradigm applied in the study and the contribution of different types of knowledge and expertise, and how this will impact on possibilities for taking on advice. Finally, responding to recommendations uses up research team resources, and the costs can be reduced by using the three implementation criteria.

Using blended and guided technologies in a university course for scientist-practitioners: teaching applied behaviour analysis to autism professionals

Although the incidence of autism spectrum disorders is increasing worldwide, there is a shortage of professionals trained to provide effective interventions. The article describes an advanced university course in Applied Behaviour Analysis (ABA) and autism tailored to meet the needs of Swedish professionals from multiple disciplines. The course implemented both blended-learning technologies (web, telecommunication, and in vivo) and guided-design (problem-solving) exercises to promote the scientist-practitioner model. Overall, students advanced their skills related to identifying extant scientific literature, choosing appropriate single-subject design evaluation methods, and critically analysing the effects of attempted interventions. Students rated the course as having high social validity and predicted the course content would positively affect their professional practice. The relevance of the course and future directions are discussed in the context of meeting the global need for effective autism intervention professionals.

AACAP 2005 Research Forum: speeding the adoption of evidence-based practice in pediatric psychiatry

OBJECTIVES

At the 2005 Annual Meeting of the American Academy of Child and Adolescent Psychiatry (AACAP), the Academy's Workgroup on Research conducted a Research Forum entitled "Increasing Research Literacy Through the Adoption of Evidence-Based Practice (EBP) in Pediatric Psychiatry."

METHOD

Forum participants focused on speeding the adoption of EBP across five areas: EBP as the preferred heuristic for teaching research literacy, use of EBP in training programs, dissemination of EBP in clinical practice, EBP in partnership with industry, and EBP as a framework for developing practice guidelines.

RESULTS

EBP provides an easy-to-understand method for accessing and evaluating the research literature and then applying this information to decisions about patient care. Although EBP has been gaining greater visibility in pediatric psychiatry, it is far from the preferred heuristic. To move the field toward fully embracing EBP will require greater understanding of what EBP is (and is not), educating mental health professionals in EBP skills, access to EBP resources, and a commitment to apply EBP to the conceptualization and design of research protocols and practice guidelines.

CONCLUSIONS

Pediatric psychiatry would benefit from a principled commitment to follow other areas of medicine in adopting EBP.

Does evidence-based medicine apply to psychiatry?

Evidence-based psychiatry (EBP) has arisen through the application of evidence-based medicine (EBM) to psychiatry. However, there may be aspects of psychiatric disorders and treatments that do not conform well to the assumptions of EBM. This paper reviews the ongoing debate about evidence-based psychiatry and investigates the applicability, to psychiatry, of two basic methodological features of EBM: prognostic homogeneity of clinical trial groups and quantification of trial outcomes. This paper argues that EBM may not be the best way to pursue psychiatric knowledge given the particular features of psychiatric disorders and their treatments. As a result, psychiatry may have to develop its own standards for rigour and validity. This paper concludes that EBM has had a powerful influence on how psychiatry investigates and understands mental disorders. Psychiatry could influence EBM in return, reshaping it in ways that are more clinically useful and congruent with patients' needs.

Evidence-based psychiatry: understanding the limitations of a method

Evidence-based psychiatry (EBP) is an important and useful method. However, it covers only a limited range of clinical problems psychiatrists and psychotherapists encounter in daily work. This is due to some particularities of psychiatric diagnoses and therapeutic practice. (i) The validity of psychiatric diagnoses is limited. EBP is entirely depending on diagnoses, so one of its core assumptions is of doubtful applicability in the field of psychiatry and psychotherapy. (ii) Effects of complexity are more obvious in psychiatric and psychotherapeutic cases. Owing to its conceptual bases, EBP cannot sufficiently consider such effects and is therefore of limited usefulness addressing particular problems in fluctuating or symptomatically shifting diseases. (iii) EBP's strong focusing on decision making does not reflect appropriately the clinical reality of psychiatrists and psychotherapists. Diagnostic and therapeutic procedures are in fact more iterative, and decisions are constantly re-evaluated. EBP is not helpful to adjust this type of individual approach, which is needed to treat individual patients.

Tacit knowledge as the unifying factor in evidence based medicine and clinical judgement

The paper outlines the role that tacit knowledge plays in what might seem to be an area of knowledge that can be made fully explicit or codified and which forms a central element of Evidence Based Medicine. Appeal to the role the role of tacit knowledge in science provides a way to unify the tripartite definition of Evidence Based Medicine given by Sackett et al: the integration of best research evidence with clinical expertise and patient values. Each of these three elements, crucially including research evidence, rests on an ineliminable and irreducible notion of uncodified good judgement. The paper focuses on research evidence, drawing first on the work of Kuhn to suggest that tacit knowledge contributes, as a matter of fact, to puzzle solving within what he calls normal science. A stronger argument that it must play a role in research is first motivated by looking to Collins' first hand account of replication in applied physics and then broader considerations of replication in justifying knowledge claims in scientific research. Finally, consideration of an argument from Wittgenstein shows that whatever explicit guidelines can be drawn up to guide judgement the specification of what counts as correctly following them has to remain implicit.Overall, the paper sets out arguments for the claim that even though explicit guidelines and codifications can play a practical role in informing clinical practice, they rest on a body of tacit or implicit skill that is in principle ineliminable. It forms the bedrock of good judgement and unites the integration of research, expertise and values.

Who decides what evidence is? Developing a multiple perspectives paradigm in mental health

OBJECTIVE

To compare different perspectives on evidence in relation to mental health care.

METHOD

The method and materials constitute a selective literature review comparing key elements of evidence-based medicine and evidence-based policy with perspectives on evidence from users, carers and professionals. The aim was to develop an argument concerning these comparisons.

RESULTS

What constitutes evidence from the perspectives of different stakeholders is a field of contestation.

CONCLUSION

It is timely for a multiple perspective paradigm on evidence in science to be developed and this paper initiates this process in relation to mental health care.

Provider-perceived barriers and facilitators for ischaemic heart disease (IHD) guideline adherence

RATIONALE, AIMS AND OBJECTIVES

Clinical practice guidelines have become a standard way of implementing evidence-based practice, yet research has shown that clinicians do not always follow guidelines.

METHOD

As part of a larger study to test the effects of an intervention on provider adherence to ischaemic heart disease (IHD) guidelines, we conducted five focus groups at three Veterans Administration Medical Centers with 32 primary care providers, cardiologists, and internists to identify key barriers and facilitators to adherence of the guidelines. Using content analysis, responses were grouped into categories.

RESULTS

The main perceived advantages of using the IHD guidelines were improvements in quality and the cost of care. Perceived barriers were the lack of ability of guidelines to manage the care of any one individual patient, the difficulty of accessing guidelines, and high workloads with many complex patients. While providers agreed on the benefits of aspirin, beta-blockers and angiotensin converting enzyme inhibitors, barriers for use of these medications were lack of consensus about contraindications, difficulty in providing follow-up during medication titration, and lack of patient adherence. Sources of influence for guideline use were: professional cardiology organizations, colleagues, mainly cardiologists, and key cardiology journals. However, most providers acknowledged that following guidelines was a personal practice decision.

CONCLUSIONS

While results validated the influences of using clinical practice guidelines, our results highlight the importance of ascertaining guideline-specific barriers for building effective interventions to improve provider adherence. An advisory panel reviewed results and, using a modified nominal group process, chose implementation strategies targeting key barriers.

Evidence-based mental health policy: a critical appraisal

BACKGROUND

Arguments for and against evidence-based psychiatry have mostly centred on its value for clinical practice and teaching. Now, however, use of the same paradigm in evaluating health care has generated new problems.

AIMS

To outline the development of evidence-based health care; to summarise the main critiques of this approach; to review the evidence now being employed to evaluate mental health care; and to consider how the evidence base might be improved.

METHOD

The following sources were monitored: publications on evidence-based psychiatry and health care since 1990; reports of randomised trials and meta-analytic reviews to the end of 2002; and official British publications on mental health policy.

RESULTS

Although evidence-based health care is now being promulgated as a rational basis for mental health planning in Britain, its contributions to service evaluation have been distinctly modest. Only 10% of clinical trials and meta-analyses have been focused on effectiveness of services, and many reviews proved inconclusive.

CONCLUSIONS

The current evidence-based approach is overly reliant on meta-analytic reviews, and is more applicable to specific treatments than to the care agencies that control their delivery. A much broader evidence base is called for, extending to studies in primary health care and the evaluation of preventive techniques.

Evidence-based medicine and psychiatric practice

Evidence-based medicine (EBM) has been defined as "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients." EBM requires the ability to apply a knowledge of medical informatics (e.g., efficiently searching the medical literature) and clinical epidemiology (e.g., being able to critically appraise the literature) to the treatment of individual patients. This article provides an introduction to the history, philosophy, and methods of EBM as applied to psychiatric practice. The article summarizes the five-step EBM model: (1) formulate the question; (2) search for answers; (3) appraise the evidence; (4) apply the results; and (5) assess the outcome. Resources (including Web sites) for further learning are provided.

Difficulties in conducting a randomized controlled trial of health service interventions in intellectual disability: implications for evidence-based practice

BACKGROUND

In an era of evidence-based medicine, practice is constantly monitored for quality in accordance with the needs of clinical governance (Oyebode et al. 1999). This is likely to lead to a dramatic change in the treatment of those with intellectual disability (ID), in which evidence for effective intervention is limited for much that happens in ordinary practice. As Fraser (2000, p. 10) has commented, the word that best explains "the transformation of learning disability practice in the past 30 years is 'enlightenment'." This is not enough to satisfy the demands of evidence, and Fraser exhorted us to embrace more research-based practice in a subject that has previously escaped randomized controlled trials (RCTs) of treatment because of ethical concerns over capacity and consent, which constitute a denial of opportunity which "is now at last regarded as disenfranchising".

CONCLUSIONS

The present paper describes the difficulties encountered in setting up a RCT of a common intervention, i.e. assertive community treatment, and concludes that a fundamental change in attitudes to health service research in ID is needed if proper evaluation is to prosper.

Evidence-based medicine: an introduction for psychiatrists

Evidence-based medicine (EBM) has been defined by Sackett as "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients." Practicing evidence-based medicine requires the ability to apply a knowledge of medical informatics and clinical epidemiology to the treatment of individual patients. This article provides an introduction to the history, philosophy, and methods of evidence-based medicine for psychiatrists and other mental health professionals. The article focuses on a systematic approach to efficiently finding the best evidence to answer clinical questions. Particular emphasis is given to a method for critically appraising papers that emphasizes validity, importance, and clinical applicability. Resources for further learning are provided.

Pharmacologic treatment of schizophrenia: what the future holds

The advent of the newer "atypical" antipsychotics has revolutionized pharmacologic treatment of schizophrenia (SZ) and other psychotic disorders. In contrast to the first-generation conventional neuroleptics, these second-generation antipsychotic agents possess a broader spectrum of efficacy and cause fewer motor side effects such as extrapyramidal symptoms and tardive dyskinesia. Despite their substantial advantages, however, these second-generation agents also have significant limitations in terms of both efficacy and adverse effects. Several strategies to address these shortcomings are currently under study and some of these are likely to become part of our therapeutic armamentarium in the future. Current shortcomings in the pharmacologic treatment of SZ and strategies under investigation to address each of these deficiencies are reviewed. New formulations of existing medications and new antipsychotics under development are discussed. Developing adjunctive treatment strategies to address each of the major psychopathologic domains in SZ are summarized. The potential application of genetic information to treatment-matching in SZ is reviewed and likely refinements in the practice of evidence-based medicine in the pharmacotherapy of SZ are considered.

Examining diagnostic tests: an evidence-based perspective

Diagnosis is an important aspect of physical therapist practice. Selecting tests that will provide the most accurate information and evaluating the results appropriately are important clinical skills. Most of the discussion in physical therapy to date has centered on defining diagnosis, with considerably less attention paid to elucidating the diagnostic process. Determining the best diagnostic tests for use in clinical situations requires an ability to appraise evidence in the literature that describes the accuracy and interpretation of the results of testing. Important issues for judging studies of diagnostic tests are not widely disseminated or adhered to in the literature. Lack of awareness of these issues may lead to misinterpretation of the results. The application of evidence to clinical practice also requires an understanding of evidence and its use in decision making. The purpose of this article is to present an evidence-based perspective on the diagnostic process in physical therapy. Issues relevant to the appraisal of evidence regarding diagnostic tests and integration of the evidence into patient management are presented.

Recent advances in evidence-based psychiatry

BACKGROUND

There is increasing interest in the potential contribution of evidence-based medicine to clinical decision making in psychiatry. In this article, we describe some of the recent advances in evidence-based psychiatry and outline future challenges.

METHOD

Narrative review.

CONTENT

The successful introduction of evidence-based practice into psychiatry requires the acquisition of new skills by clinicians. It is also important that policy statements that aim to be evidence-based, such as clinical practice guidelines, use rigorous methods to synthesize the primary evidence and do not overlook its limitations. One result of the systematic reviewing of evidence is the identification of important residual clinical uncertainties. Primary research can then be focused on these questions. For questions regarding therapy in psychiatry, it will be necessary to undertake some large, simple randomized trials. Making the best available evidence readily accessible in a clinical setting, however, remains a significant challenge.

CONCLUSIONS

Collaboration between clinicians, researchers, policy-makers, and those involved in information technology is required to optimize the contribution of evidence-based medicine in psychiatry.

EBM in practice: psychiatry

Psychiatry was one of the first medical specialties to use the tools of evidence-based medicine (EBM)--randomised controlled trials (RCTs), systematic reviews with meta-analyses--and as many treatment decisions in psychiatry are evidence-based as in general medicine. Psychiatrists have some reservations about the EBM approach because of perceived limitations in methodology of RCTs and systematic reviews; gaps in the evidence base; problems interpreting the available evidence; and neglect of individual patient uniqueness in quantitative research based on groups or populations. Research supports the value of psychotherapy and there are now a number of empirically validated efficacious psychotherapies for a range of disorders.

Psiquiatria baseada em evidências

Em psiquiatria, observa-se grande variabilidade de práticas clínicas, muitas vezes desnecessária. Essas variações podem estar relacionadas à ausência de evidência científica confiável ou ao desconhecimento das evidências de boa qualidade disponíveis. A medicina baseada em evidências (MBE) é uma combinação de estratégias que busca assegurar que o cuidado individual do paciente seja baseado na melhor informação disponível, a qual deve ser incorporada à prática clínica. Neste artigo, conceitos de MBE são discutidos com relação a aspectos e desafios no tratamento de pacientes com distimia, bulimia nervosa e esquizofrenia. A partir de resultados de três revisões sistemáticas recentemente publicadas, conclui-se que a prática de psiquiatria baseada em evidências acrescenta qualidade à prática psiquiátrica tradicional.

Evidence-based psychopharmacology 1. Appraising a single therapeutic trial: what is the evidence for treating early Alzheimer's disease with donepezil?

Expertise in setting appropriate, answerable clinical questions, undertaking an accurate search of databases, and appraising the evidence found are all key elements to practising evidence-based medicine. Using the published evidence of the utility of donepezil in Alzheimer's disease as an example, I have attempted to illustrate the process of critical appraisal of a therapeutic intervention. The study appraised was well conducted and the results indicate that donepezil may benefit some patients with Alzheimer's disease.

Methodological issues concerning evaluation of treatment for sexual offenders: randomization, treatment dropouts, untreated controls, and within-treatment studies

The value of randomized controlled trials in evaluation of sexual offender treatment has been questioned. Concern was expressed that randomization fails to produce equivalent samples, without apparent appreciation this is inevitable when variables are distributed by chance; lack of equivalence is controlled by use of tests of significance. A further uncriticized and inappropriate procedure in treatment evaluation is separation of the results of subjects who did not complete treatment from those who did, when the outcome of the former group was known. Despite an APA Task Force recommendation, no attention has been given to the consistent finding that no treatment is less effective than placebo psychological therapies. The significance of Type II errors is discussed and the recommendation criticized that within-treatment research be encouraged as an alternative to outcome research. Demonstrating a within-treatment response when that response is associated with a better outcome does not necessarily mean that the treatment was effective. Subjects with a good prognosis could be more able to demonstrate a within-treatment response to the treatment. Nonrandomized matched samples do not adequately control all sample differences. The post hoc statistical reversal of a reported trend for sexual offenders treated with relapse prevention to show a worse outcome than untreated offenders, in order to correct lack of equivalence of the two groups, is considered inappropriate. That relapse prevention was found less effective than no treatment raises the possibility that it has a negative effect. To continue the use of relapse prevention other than in randomly controlled evaluative studies would appear to be unethical.

Research utilization and attitudes towards research among psychiatric nurses in Northern Ireland

Evidence-based practice depends on a number of factors including practitioners' attitudes towards, and knowledge of, research, the availability and access to relevant research, adequate resources and managers' support. Yet little is known about these issues with regard to psychiatric nurses. The aim of this study was to survey psychiatric nurses on their attitudes to research, their perceptions of their use of research and other research-related activities. This paper reports data collected from a convenience sample of 236 nurses from the six main psychiatric hospitals and from the psychiatric wards of six general hospitals. The results show that, while they report positive attitudes towards research, their perception of their use of research in practice indicates that evidence-based practice is far from being realized. There is also some evidence to suggest that psychiatric nurses' reported extent of research utilization and frequency of reading research literature in this study are lower than those of general nurses. The implications of these and other findings are discussed.

Drug treatment of mania: a critical review

While lithium is generally considered to be a first-line treatment for mania, the position of the anticonvulsants and the antipsychotics in the treatment of this disorder is currently under debate. For that reason, this paper reviews the original literature, in particular addressing the randomized controlled trials (RCTs) on lithium, anticonvulsants and antipsychotics, and the methodological limitations therein. As the treatment of mania needs to anticipate the future course of the illness, the data on prophylaxis will also be reviewed, albeit briefly. It is concluded that antipsychotics are powerful antimanics, which are particularly beneficial for some clinical presentations of severe mania. However, in general their use should not be prolonged into the maintenance phase. Lithium is still to be considered the mood-stabilizing drug par excellence, although it may be insufficient in mixed states and severe mania. The evidence for antimanic efficacy of valproate, in particular for mixed states, seems more convincing than that for carbamazepine, while the evidence for a prophylactic action of carbamazepine still exceeds that for valproate. Adjunctive treatment with benzodiazepines is often useful. Small sample sizes, highly selected study populations and high drop-out rates seem to be the most important limitations of the RCTs on mania. Quasi-experimental, naturalistic studies on unselected populations are needed to investigate how the various treatments work in clinical practice. Based on the available evidence, summary guidelines for treatment are proposed.