How to Practice Evidence-Based Psychiatry: Basic Principles and Case Studies

Our field is suffused with evidence-based medicine. The assumption that improving quality of care indices is the path to improving health outcomes is virtually unchallenged. Residency training programs, as is pointed out at several junctures in this volume, are mandated by the Accreditation Council for Graduate Medical Education to address competency in "practice-based learning and improvement," under the aegis of which a variety of quality-based activities, including evidence-based medicine, are taught. But how does one practice and teach evidence-based medicine? Taylor's book seeks to provide relevant tools to three groups: practitioners, residents and other mental health trainees, and residency training directors seeking resources with which to develop evidence-based medicine curricula. The first third of the book consists of a series of historical, philosophical, and methodological chapters that presents the underpinnings of evidence-based medicine, while the remaining two-thirds of the book presents a series of "case studies" that illustrate how evidence-based medicine techniques can be applied to particular disorders or in particular systems. The book builds on a prior American Psychiatric Publishing volume by Gregory E. Gray (1), who is author or coauthor of 13 of the 17 chapters that comprise the book's first section.

There is much to like about this book. By far the most valuable information is contained in the first section, in which the principles and techniques of evidence-based medicine are laid out in a sophisticated but nontechnical fashion. The level of presentation is aimed where it should be for the stated audience: to support the development of good consumers of research, rather than to train researchers. I have not seen another resource that brings together in one volume clinician-oriented summaries of principles of clinical trial design, meta-analytic techniques, the theory and practice of clinical practice guidelines, test performance, and the basics of clinical epidemiology. Some of the chapters are truly unique, like the one on how to search the medical literature effectively and efficiently—the present-day problem being, of course, not how to get information but rather how to get rid of information.

Much weaker are the early chapters on such topics as the difference between evidence-based medicine and what Barr and Gray call "evidence-based psychiatric practice," and how to ask an "answerable question." One wishes as well that they had instead used the space for a chapter on the basic—but far from self-evident—statistical techniques that are the foundation of clinical studies from basics like means, medians, and proportions to the more complex but equally common techniques, such as logistic regression, survival analysis (beyond the single example on p. 118), and the all-important topic of how to manage missing data and its effect on analyses.

In comparison to the first section, the case studies that make up the bulk of the book were not as a whole particularly useful. While a few examples certainly help to amplify points made in the first section, the reader reaches the point of diminishing returns quite early in the almost 200 pages of case studies. That said, one does encounter a variety of potentially useful tools, like the Systematic Treatment Enhancement Program for Bipolar Disorder clinical monitoring form in the chapter by Wang and Ketter or Taylor's examples of how to organize and chart longitudinal data on bulimic and depressive symptoms.