1 Boring Old Man: On antidepressants and clinical judgement

"a restrictive interpretation…"

1 Boring Old Man (retired psychiatrist Mickey Nardo) wrote: 

Those who support the Black Box Warning rely on individual instances – their own experience as patients and clinicians or the case reports of others. People who oppose the Warning point to studies in populations that show no effect either way on suicide, but confirm that the prescription rate of SSRIs either fell or stopped rising in response to the Warning.

And then he linked to this article:

The Clinical Inadequacy of Evidence-Based Medicine and the Need for a Conceptual Framework Based on Clinical Judgment

by Fava GA, Guidi J, Rafanelli C, and Sonino N

Psychotherapy and Psychosomatics. 2015 84:1-3.

[full text on-line]

[full text on-line, pdf]

It’s a short two paged article best read as a narrative rather than viewed in a couple of sound bytes, so I’ll skip any attempt at summary. It’s an article that talks about clinical judgement taking precedence over the tenets of evidence-based medicine. It’s a hard argument to make as it can be instantly met with "How do you know that?" or "But that’s just what you think." And I’ve actually never heard any two people have this argument with even slightly changed minds as a result.

My own opinions are embedded in my narrative.

I don't know if it is possible to change anyone's mind in an argument, but I do know that the opinions embedded in dr Nardo's narrative makes good reading for a psychiatric survivor like me. He ends with a quote from the article:

The conceptual model that has generated EBM and guidelines clashes with clinical reality and fosters a dichotomy between medical science and clinical judgment. EBM has certainly made an important contribution to questioning unsubstantiated therapeutic claims. The time has come, however, to become more aware of its considerable limitations, including overall reductionism, disregard of patient-physician relationships and patient preferences, and insufficient consideration of problems related to financial conflicts of interest. As an increasing body of literature indicates, EBM offers only a restrictive interpretation of the scientific approach to clinical practice.

And I will end with a paper on evidence-based medicine: 

According to Altmetrics, our paper on #RealEBM was 2014's most tweeted-about paper in @bmj_latest. http://t.co/ckOMxppZVT
— Trisha Greenhalgh (@trishgreenhalgh) December 26, 2014+++