Levine Robert, Fink Max
Clinical Psychiatry, New York University College of Medicine, 1236 Park Avenue, New York, NY 10128, USA.
Med Hypotheses. 2006;67(2):401-10. doi: 10.1016/j.mehy.2006.02.025. Epub 2006 May 4.
There is an organized movement by governmental, academic and commercial interests to make evidence-based practice the standard of care in the United States. There is little proof that this model can be adapted to psychiatry. We examine the diagnostic system, the validity of the data from clinical trials and how these are applied to clinical practice. The discipline of psychiatry relies on imprecise and unstable diagnostic criteria. It divides psychiatric disorders into discrete categories based on discussion and consultations among designated experts in the field. The diagnostic system is based on consensus and not experimental evidence. In fact, psychiatric disorders are not discrete. High co-morbidities between disorders and the propensity of one condition to change into another makes the present diagnostic system extremely questionable. Outcomes of clinical trials are defined by fractional reductions in the number and severity of symptoms measured by rating scales and not remission of illness. The data obtained from clinical trials are flawed in design, execution and the selective reporting of outcomes. There is substantial evidence to indicate that both investigators and patients can distinguish between active treatment and placebo in double blind studies. In addition, negative outcomes are frequently not reported. Such evidence impacts not only on the specific study, used as evidence, but invalidates the value of meta analyses. Financial considerations lead to the inclusion of inappropriate subjects into studies and favor newer, patented treatments. When the conclusions derived from evidence-based psychiatry are applied to clinical practice they have little to offer and often produce poor treatment outcomes. In fact, when the data used to support the principles of evidence-based psychiatry are examined, they are unsound. The system itself is best considered an untested hypothesis. The diagnostic system, the manner in which data are gathered, and financial factors combine to produce a system that is misleading and indeed, dangerous.
在美国，政府、学术和商业利益集团发起了一场有组织的运动，试图将循证实践作为医疗护理的标准。几乎没有证据表明这种模式可以适用于精神病学。我们审视了诊断系统、临床试验数据的有效性以及这些数据如何应用于临床实践。精神病学学科依赖于不精确且不稳定的诊断标准。它基于该领域指定专家之间的讨论和协商，将精神疾病分为不同的类别。诊断系统是基于共识而非实验证据。事实上，精神疾病并非是离散的。疾病之间的高共病率以及一种病症转变为另一种病症的倾向使得当前的诊断系统极具问题。临床试验的结果是通过评定量表测量的症状数量和严重程度的分数降低来定义的，而非疾病的缓解。从临床试验中获得的数据在设计、实施以及结果的选择性报告方面都存在缺陷。有大量证据表明，在双盲研究中，研究者和患者都能够区分活性治疗和安慰剂。此外，负面结果常常未被报告。这样的证据不仅影响用作证据的具体研究，还使荟萃分析的价值无效。经济因素导致不适当的受试者被纳入研究，并倾向于采用更新的、有专利的治疗方法。当将循证精神病学得出的结论应用于临床实践时，它们几乎没有什么作用，而且往往会产生糟糕的治疗结果。实际上，当审视用于支持循证精神病学原则的数据时，会发现它们是不可靠的。该系统本身最好被视为一个未经检验的假设。诊断系统、数据收集方式以及经济因素共同作用，产生了一个具有误导性且确实危险的系统。
