Joltvolta (great name, by the way), asked a good question after I
posted part 3.
When you say proceed methodically, employ good data
collection, etc. How does the individual do that for themselves? If
they don’t have the availability to see a specialist multiple times a
week, or even in a month, what options do they have?
I will get to that, eventually, but there are a few more things I have
to cover first. After all, part of my agenda in writing this
series is to enable patients to do more for themselves. There is
a shortage of specialists, and so long as that is the case, it will be
good for people to do more for themselves. In fact, one could
argue, that it is always good for people to do more for themselves,
regardless of the supply of specialists.
After considering the concept of the adequate trial, covered in part
3, it is natural to extend that concept to a sequence over
time. That is, the proper selection of antidepressants occurs
during the course of a sequence of adequate trials.
Here is an important concept to understand: every medication trial in
psychiatry serves two purposes. One purpose is to help the
individual get better now. The second purpose it to gain a better
understanding of how the individual responds to various medications:
what good things happen with what medications, and what bad things
happen with those medications, and which medications make no
difference, all in that one person?
At the point in time when the first medication is selected, there is no
information about how a given patient responds to medication.
Therefore, the main source of information is the studies that were done
on other patients. The more medication trials a given
patient has undergone, the more patient-specific information we
have. This shifts the balance: the research studies progressively
become less important; the patient-specific information
progressively becomes more important.
Notice, however, that the two purposes sometimes create a
tension. One purpose is to get the patient better now. That
would seem to argue for short trials with aggressive dosing. But
if you do that, you sacrifice the second goal. If you do not
proceed slowly and methodically, you do not gain the maximum amount of
patient-specific information. You are not doing adequate
Different psychiatrists differ in how they approach this. Some
are quick to abandon a trial in order to try something new.
Others are more likely to proceed methodically. Of course, the
patient has a say in all this; some want to forge ahead with new trials
prematurely, and others are content to wait it out. Some
psychiatrists take the patient’s desires into account fairly heavily,
whereas others are less inclined to modify their approach according to
the patient’s wishes.
So, in case you are wondering why I am well into the fourth part of
this series, and have not yet mentioned the phrase, “evidence-based
medicine,” now you know. It is because evidence-based
only a part of the entire picture. In order to understand the
role of EBM, you have to see how it fits in to the broader context of
The people who write about EBM understand this. They do not
propose that we abandon clinical judgment. They do not propose
that we treat each patient the same. What they propose is that we
use the results of research as much as is clinically appropriate.