Abstract
We now live in an era of evidence-based medicine (EBM). As clinicians we are expected to use evidencebased approaches. Systematic reviews and meta-analyses are regularly presented at conferences and continuing educationmeetings. Psychiatric trainees are nowassessed in their critical appraisal skills, and EBM is part of medical school curriculum.
The College has recognized the importance of EBM and produced a set of Clinical Practice Guidelines to support clinicians using an evidence-based clinical practice. Regrettably, there is still some misunderstanding of what evidence-based medicine really is (it is not just reading a systematic reviewand using the recommended treatment) and how to use an evidence-based approach routine in clinical practice. There are generations of psychiatrists for whom Evidence-Based Medicine is a mystery – (with strange new statistics like ‘Numbers Needed to Treat’) and who have not been taught critical appraisal skills or how to apply evidence in routine clinical practice.
While there are a number of texts on evidence-based medicine [1–3] to help understand what it is all about, they do not focus on mental health issues and are often overly technical making them inaccessible. A practical and accessible book focusing on evidence-based approaches in mental health is therefore most welcome. This book, based on a course two of the authors ran at the University of Auckland, fills that gap well.
The authors follow a standard approach in reviewing the skills required for evidence-based medicine, particularly explaining in detail how to formulate clinical questions (a fundamental issue in EBM), using the PICO method (Population of interest, Intervention, Comparison and Outcome). They carefully go through this with regard to the common types of clinical questions to do with diagnosis, aetiology, therapy, prognosis and so on. This is followed by an excellent chapter on searching the literature. They review the methods of doing this and discuss the widely used databases that will be very useful to clinicians who may be overwhelmed with searching databases such as PubMed or Medline. They avoid this becoming a sterile discussion by providing exercises for the reader to do using the practical clinical vignettes.
Having created a platform for EBM the authors then methodically go through how to critically appraise the research literature on treatment, systematic reviews and meta-analyses, guidelines, prognosis, rating scales and qualitative research. Each of these chapters is supported by practical examples of how to search for, and apply the evidence, along with explanations of the tools that are used to quantify the evidence. While these are generally clearly described, there are instances when the explanations can be confusing; for example, the discussions of risk reduction (although this may reflect a general confusion in the plethora of terms that are used) where they use a mix of proportions and percentages, which makes it difficult for the reader to follow. I did not find the discussion on funnel plots to detect publication bias particularly clear, but this is a complex area.
One problem with the book is that there are some typographical errors that need to be corrected (hopefully in a 2nd edition) – for example, in the chapter on metaanalysis – the text states “if there are a sufficient number of excluded studies,…” when it should have been ‘included studies’.
Overall I found this book easy to read, informative and practical. I would recommend it to all trainees to assist them with critical appraisal and clinical supervisors (who have to run journal clubs and prepare trainees for the written assessment) and all psychiatrists wanting to know about EBM. This book should be available tomembers of mental health teams to assist them in their journal clubs.