Psychiatry and Evidence-Based Psychiatry: A Distinction with a Difference

Evidence-based medicine (EBM) made its first appearance in the medical lexicon in 1990 and since then has enjoyed widespread support from within the medical profession, including among psychiatrists. Proponents of evidence-based psychiatry (EBP) point to its ability to demonstrate the efficacy of various psychiatric treatments, promising improved mental health outcomes and more efficient use of healthcare resources as a result. Policymakers and insurers have embraced EBP in hopes that these goals will be realized. However, the question of whether EBM is even applicable to psychiatry remains largely unaddressed, even though it is an urgent one, given the various corporate, professional, and governmental pressures to practice according to its principles.

In their article, Thomas, Bracken, and Timimi (2012) address the fundamental question of whether there are features of psychiatric problems, or their treatment, that require the reconsideration of EBM’s relevance to psychiatry (as distinguished from other medical specialties). Their paper begins by arguing that, because it is oriented toward picking out the effects of specific components of treatments, EBM’s methods tend to neglect unspecified aspects, such as the placebo effect and the so-called nonspecific psychotherapeutic factors. The authors then consider EBP using the interpretive lens of Kuhn’s concepts of normal science, paradigm, and anomalies. They argue that these unspecified elements are ‘anomalies’ in Kuhnian terms within the EBM ‘paradigm.’ Although others have critiqued the use of Kuhn’s language in association with EBM (Benitez-Bribiesca 1999), the authors use it to provide an engaging and plausible description of how certain data (anomalies) are ignored by both scientists and clinicians. From here, the paper explores the nature of subjectivity and the question of whether scientific accounts of subjectivity can ever be complete. The authors conclude by arguing that psychiatric problems and their treatment fundamentally concern subjectivity, a scientific account of subjectivity is incomplete at best, and that an effective and ethical discipline of psychiatry requires at the very least, a complementary focus on culture, values, narrative, and context.

With their overall conclusion, I take no issue. Psychiatry—its theory, education, and practice— would be greatly improved through the systematic inclusion of all sorts of knowledge—professional, academic, intersubjective, and experiential—as part of its approach to problems. However, I do think there is an area of confusion that runs throughout the analysis. The authors critique alternately scientific, biological, and technical approaches to psychiatry and, although they do not claim these terms are interchangeable, they do not distinguish sufficiently between them. As a result, the authors attribute certain assumptions or approaches to EBM when they are more rightfully the domain of psychiatry itself. It is sometimes unclear in the paper whether the authors’ main objections lie with EBM or with mainstream psychiatry, particularly a biological view of psychiatric disorders and their treatments. This is an important point to clarify because potential remedies depend greatly on where one locates the fault.

EBP Versus Psychiatry

EBM’s primary concern lies with justifying medical knowledge: under what circumstances can we consider a claim (about diagnosis, prognosis, treatment, and harm) justified?¹ The answer lies in adherence to the evidence hierarchy, EBM’s central concept. The hierarchy is a non-exhaustive ranking of research methods from those most likely to least likely to yield truthful conclusions about the subject under investigation. Because research methods are arranged hierarchically, phenomena best captured by the methods at the top of the hierarchy are also prioritized. As a result, EBM is not only about how to know things in medicine, but what we ought to know.

Given the popularity of EBM-preferred research methods among funders, insurers, and policy-makers, the more that psychiatric interventions conform to the theoretical demands of EBM, the greater the likelihood that they will receive scientific attention, research funding, and perhaps insurance funding for clinical use. Thus, there is considerable pressure for psychiatry to assume the evidence-based identity and to adopt its philosophical position and assumptions. For psychiatry, this includes a move toward a conception of mind and mental disorder that is behavioral (because this is what...