John M. Diamond, MD

Professor and Head, Division of Child and Adolescent PsychiatryBrody School of Medicine atEast Carolina University

EBM is a term used and misusedIsn’t medical “science” all about evidence?Why the controversy recently about mammograms?Example of treating corneal abrasion

Gap between knowledge from clinical trials and actual treatmentPractice often lags years behind research findingsStudies are in progress, results presented, published, disseminated, but what causes a change in practice?Surveys in academic centers found up to 40% of clinical decisions unsupported by research evidence (power of “experience”)

Information overload, with thousands of journals and millions of articlesSmall studies are often contradictoryMany false positives and false negativesReview articles are often narrative, and not systematicOver-reliance on experience, expert opinion, and results from single studiesExcessive influence of pharmaceutical companies

Partly a philosophy, partly a skill, partly the application of a set of tools“The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients…involving the integration of best research evidence with clinical expertise and patient values.1

Emphasis on patient preferences and values

1Sackett, DL (2000): Often known as the “father” of EBM

Double blind placebo controlled studiesAppropriate dosingIntention to treatRandom selectionBeware of bias of reporting only positive results--need for good replicationsThere are levels of evidence, including experience, but that is the lowest level

Diagnosis by symptoms: sadness; worries; moodiness; activity levelDiagnosis by medication responsePolypharmacy: two meds of one class, multiple meds focusing just on symptoms and side effectsReliance on expensive, new medicationsChildhood Bipolar DisorderReactive Attachment Disorder

ADHD--StimulantsOCD--SSRIs, clomipramineEnuresis--imipramine, DDAVPDepression—fluoxetine, escitalopramTourette’s Disorder--pimozide, haloperidolBipolar Disorder--risperidone (10-17), aripiprazolePsychotic Disorder--risperidone, aripiprazole, haloperidolAutism--risperidone

Cognitive-Behavioral Therapy for Depression, Anxiety, OCDParent Training/Education for disruptive behaviorsStimulant medication for ADHD