The Limits of Evidence-Based Medicine and Its Application to Mental Health Evidence-Based Practice: Part One
Gomory, Tomi, Ethical Human Psychology and Psychiatry
The present article outlines the major limitations of evidence-based medicine (EBM) and through a close review demonstrates that the three component EBM process model is a pseudoscientific tool. Its "objective" component is the collection, systematic analysis, and listing of "effective" treatments applying a research hierarchy from most rigorous (systematic reviews of randomized controlled trials [RCTs]) to least rigorous (expert opinion). Its two subjective components are the clinical judgment of helping professionals about which "evidence-based" treatment to select and the specific and unique relevant personal preferences of the potential recipients regarding treatment. This procedural mishmash provides no more rigor in choosing "best practice" than has been provided by good clinical practitioners in the past because both turn out to be subjective and authority based. The article also discusses EBM's further methodological dilution in the National Insti- tute of Mental Health (NIMH) endorsed Evidence-Based Mental Health Practice (EBP) movement. In EBP, the allegedly rigorous EBM protocol is altered. Instead of systematic expert protocol-driven EBM reviews of RCTs, NIMH sanctioned expert consensus panels decide "evidence-based practices." This further problematizes the development of best practices in mental health by converting it to a political process. The article concludes with some observations on these issues. In a second article (part two) forthcoming, assertive community treatment (ACT) is examined as an example of an EBP that fails as a scientifically effective treatment despite its EBP certification and general popularity among practitioners.
Keywords: clinical practice; evidence-based medicine; evidence-based practice; mental health; social work
No profession is free of dogmatic clowns.
-Jacobsen, 2009, p. 19
The relatively recent phenomena of evidence-based practice (EBP) in mental health is derived analogically from the dramatic growth and resulting assertion of legitimacy of its parent movement, evidence-based medicine (EBM). Mental health EBP as a result depends on the concept of disease as the target of amelioration and presumes its validity in understanding and responding to the complex human existential travails that are the problems addressed in mental health. As Thomas Insel (2007), the director of the National Institute of Mental Health (NIMH), tells us, "as [mental health] research during the Decade of the Brain ( 1990-2000) forged the bridge between the mind and die brain, research in die current decade is helping us to understand mental illnesses as brain disorders" (p. 757). In 2010, the NIMH budget was $1.5 billion, most of it ear- marked for research on the severely mentally ill (SMI) and their treatments. Almost a third of the funding, about $400 million, was spent on brain and basic behavioral research (NIMH, n.d.) designed to verify NIMH's institutional assumption that mental illnesses are brain diseases.
This bald-faced declaration by the director of the NIMH, the institution that disburses the overwhelming majority of mental health research dollars and outlines the direction of all acceptable mental health research programs in the United States, in die absence of any physiological markers or identified lesions that would be diagnostic of even a single currently listed mental disorder within the Diagnostic and Statistical Manual of Mental Disorders (DSM; American Psychiatric Association, 2000) seems to be putting the cart well before the horse but has not disturbed the mental health helping professions and their EBP (Gomory, Wong, Cohen, & Laçasse, 2011).
This article will first briefly describe EBM and dien identify its problems. Then it will describe its reworked version as EBP applied to mental healdi in die United States and discuss its problems. Anodier article (part two) forthcoming in this journal will provide a specific example of how it can all go wrong by reviewing assertive community treatment (ACT) perhaps the most well documented EBP certified by die NIMH that has been around for more than 40 years. …