Adopting Evidence-Based Treatments

Over the last five years, the concept of evidence-based treatment in psychiatry has steadily taken hold, despite concerns about cookbook medicine and the marginalization of treatments that have yet to be adequately researched. The body of scientific evidence continues to grow, and residency programs are increasingly including training in the use of evidence-based approaches. However, a number of obstacles remain to the widespread adoption of evidence-based treatment in private clinical settings.

A low percentage of psychiatrists use evidence-based treatment, Ranga Krishnan, M.B., Ch.B., chairperson of Duke University's department of psychiatry and behavioral sciences, told Psychiatric Times. It has not been part of the core of training programs in general. By contrast, fields such as cardiology and oncology have developed a lot of data and include evidence-based approaches as part and parcel of curriculum and training.

Somewhere along the line, people made the assumption that the level and quality of data is not as good in mental health as in other fields, but that's not true, Krishnan said. The application of that data, however, has not been systematically pushed. But the field is moving in the right direction, he said. Systematic evidence-based approaches are being developed that clearly delineate levels of evidence to support treatment recommendations.

At this point, evidence-based practices are percolating into psychiatry and the mental health field relatively quickly. The annual meetings of the American Psychiatric Association have had a growing number of sessions with evidence-based in their titles, said Krishnan, who this year chaired a session titled "Evidence-Based Medicine: The Next Generation" and spoke on "How to Make Judgments Under Uncertainty."

The APA uses periodic surveys of its members to determine the degree to which psychiatrists are following treatment guidelines, which are developed by leaders in the field based on the best evidence available. The survey by leaders in the field includes basic questions such as whether physicians are using the expected medications for a given diagnosis.

"We try to get some sense of the degree to which recommendations that exist in the practice guidelines are in fact being followed in routine clinical practice," Darrel Regier, M.D., M.P.H., told PT. Regier is executive director of the APA's American Psychiatric Institute for Research and Education.

The most recent survey found clear ethnic and racial differences in terms of which patients receive atypical antipsychotics. Basically, some minority populations were less likely to get the newer drugs and more likely to get older ones that carry a higher risk of neurotoxicity and metabolic syndromes such as diabetes, he said. The survey also found a much lower level of overall compliance with guideline-recommended psychosocial treatments for schizophrenia and other severe mental disorders, including any kind of psychotherapy or supportive family therapy.

Payor Issues

Payment mechanisms certainly play a role in whether evidence-based practices are widely adopted, Regier said. For instance, he explained, "The reimbursement rates now for psychopharmacologic treatment are an order of magnitude larger than what you would get for psychotherapy."

The amount a psychiatrist gets paid for four 15-minute medication-management sessions results in a substantially higher income than does an hour of psychotherapy. For instance, a medication visit might pay $45, while a one-hour visit combining medication management with psychotherapy might pay slightly more than $100.

"What happens then is that because of some of the financial incentives, there often is not the adherence to guidelines that you would like," Regier said.

"That pattern is encouraged by the managed care companies," he said. On one hand, managed care is trying to subsidize treatment at the highest level of competence. Because only psychiatrists can prescribe drugs, managed care tries to funnel them into medication management and turns to psychologists, social workers and other less expensive professionals for psychotherapy.

However, even in the absence of payment issues, making sure that patients get treatment such as family skills training and psychosocial support services can be challenging for a psychiatrist in private practice, he said. Without direct contact with a range of specialists in social work, nursing and psychology, it becomes much harder to refer patients to those resources, he said.

There's also an educational issue, according to Regier. Knowing the effectiveness of a given treatment is important, but if psychiatrists do not have good information on the cost benefits for services that are not immediately available within their practice, they are less likely to go the extra mile to make sure that their patients get the full range of services they need. Even then, while those additional services might help the patient, they represent little more than an additional cost to the payor.

"That's one of the major problems with our system," Regier said. "The payor is not necessarily the one who gets the benefit from optimal care. The payor sometimes gets the benefit from minimal care."

Getting Informed

For most clinical situations, information on evidence-based practices is available through a variety of Web sites, such as Oxford's Centre for Evidence-Based Medicine <www.cebm.net> and Centre for Evidence-Based Mental Health <www.psychiatry.ox.ac.uk/cebmh>. Each gives clinicians free online resources for learning how to make the most of the evidence base, Krishnan said.

Information is also available through the U.S. National Library of Medicine at the National Institutes of Health <www.nlm.nih.gov>.

Evidence-based approaches are also synthesized in conference reports and are incorporated into most new practice guidelines. Krishnan said, "To say it's not easily accessible is not true anymore."

Learning how to practice evidence-based medicine doesn't take long, he said, and almost all medical schools are now providing training in evidence-based medicine.

For example, Krishnan highlighted how Duke University has included evidence-based approaches as part of its psychiatric training for the past five or six years. Residents work with him and other faculty. When psychiatry residents at Duke see a patient with a particular problem, they research the available information, write it up, present it to Krishnan and post it on the Web. It has proved to be a very effective teaching tool, he said.

The key is knowing how to evaluate the information provided, give it the proper weight and incorporate it into managing the patient. "It's not cookbook," he said.

There are many situations where the evidence is not yet available. In those cases, one is left having to follow the best available knowledge, Krishnan said. And as the evidence gets better, if it points in a different direction, then a clinician's practice must reflect that change.

Basically, the purpose of evidence-based treatment, according to Krishnan, is to reduce the effects of marketing messages for a particular treatment. However, the evidence base is not limited to psychopharmacology. There's a considerable amount of evidence-based approaches to psychotherapy, he said. But nobody is publicizing it or telling physicians where to find it.

"The common myth that's out there is that evidence-based medicine is cookbook medicine, and it's exactly the opposite," he said. A lot of the myth comes from thinking that evidence-based approaches minimize certain forms of treatment by devaluing them, but that is the opposite of what it is intended to do.

Scope of Evidence

The move toward evidence-based practice has not been without its critics. Mental health consumer and advocacy groups have voiced concern that interventions and treatments that have not received the same level of scientific scrutiny as psychopharmacology, for example, will be marginalized.

Of particular concern to groups such as the National Mental Health Association (NMHA) is that the term itself may be used to justify strategies by state agencies and insurers that are primarily intended to contain costs and limit access to treatments. The NMHA said that many policies that call themselves evidence-based are focused on data regarding symptom reduction without giving weight to clinical experience and patient outcomes.

"I think what is going to be happening more and more is that the evidence required for assessing the effectiveness of psychosocial treatments will be of the same type and magnitude of that required for psychopharmacologic treatments," Regier said. "The psychotherapies are going to need to be subject to the same kind of evidence in clinical trials."

For example, cognitive-behavioral therapy (CBT) for panic disorder is very different than CBT for depression. "You need to have specificity in your treatments for specific disorders, and I think that's the direction where the evidence-based treatments are clearly moving," he said.

Oftentimes what happens is that attention to manual-driven psychotherapies is lacking, and an eclectic amalgam of therapies gets used, he said. "When one does really careful clinical trials, you can see that the manualized therapies are clearly superior." This fall, the Residency Review Committee for Psychiatry will meet to discuss the requirements for residency training, including the five psychotherapies they deem as essential: cognitive-behavioral, psychodynamic, brief, supportive and psychotherapy combined with psychopharmacology. One of the anticipated changes, Regier said, is that whatever new residency requirements are included will need to have a scientific evidence base for it.

"I think the bar is continually being raised in terms of what the scientific base for the profession is in both the pharmacologic treatments as well as the psychosocial treatments," he said. "And we think that's a good thing."

Regier hopes it will also promote a greater attention to research on a whole range of treatments. That, in turn, would improve the effectiveness of patient care and the attractiveness of the mental health field for residents and medical students who want to go into a scientific-based discipline, he said.

Making Judgments

A fair amount of data exists on various psychosocial approaches, Krishnan said. It includes what works, what people think works but the data show does not and what people think may not work but the data shows probably does. He said, "The question is, does it fit one's own idea about it?"

People often make judgments based on their own perceptions and have a hard time integrating information when it does not appear consonant with those perceptions and biases. And that is often the problem, he said. The key is wanting to do what is right for the patient, and that means getting the best available knowledge.

However, knowledge gaps in the database do not mean a treatment shouldn't be used, he said. Rather, it still may be of use while more information develops.

At this year's APA meeting, Krishnan focused on how physicians make judgments, how biases enter into those judgments and how to de-bias information.

The tendency to fall back on biases when faced with uncertainty points to the need to adopt evidence-based approaches, Krishnan said. In the face of uncertainty, "What works 90% of the time may mislead you 10% of the time." And that 10% of the time, things can go badly. That's true whether a person is buying stocks or treating a patient, he said.

"The key here is to know what biases you're falling into," Krishnan said. It is important that "when there is an evidence base that you do use it, and incorporate it into your decision and not let your bias be the primary reason for making a decision."