I have to give a talk in a couple of weeks at a conference called – PhD today. The theme for the conference is “What does it mean to do a PhD today?” and I’m talking in a session on “Social Responsibility and Engagement”. I have been told to focus on my personal motivations for beginning study for a PhD, so I thought this would be a useful topic to put on this blog as well.
I’ve called the talk “Psychiatry – beyond measuring and counting as an outcome measure” as I want to discuss the nature of evidence based clinical practice in modern medicine, how I see this applying to clinical psychiatry and what I perceive of the limitations in the model.
Evidence based clinical practice
At medical school in the UK, and increasingly as part of Nursing education as well, practitioners are introduced to the concept of evidence based clinical practice. The underlying belief, tenet, of evidence based practice is that treatments for disease should be based on sound scientific evidence. Treatment decisions should then flow from the clinician’s understanding of the available scientific evidence as it applies to the patient before them and also from the patient’s personal preferences as regards the available options.
The evidence base in clinical practice is developed primarily through the application of clinical trials. Clinical trials seek to compare novel treatments either against inactive placebo, or current gold standard therapies. Participants, representative of the target patient population, are randomised to receive either active or control treatment. The course of their disorder is then monitored, through chosen outcome measures. so as to observe differences between trial groups.
The choice of outcome measure, target population and control condition are crucial to ensuring the trial provides valid, useful, information to develop the clinical evidence base.
The evidence based practice model and the clinical trial have provided valuable information and undoubtedly benefitted many patients through allowing for a more rational decision process. There are concerns with the paradigm however – the one that interests me most personally is how do we avoid losing sight of the individual, of subjective experience, within clinical practice amongst the development of this population level data.
Outcome measures in clinical psychiatry
Clinical psychiatry trials generally use symptom rating scales to measure response to treatments. Response is variably defined, often a 50% or greater reduction in symptom score from baseline.
Again the question remains, and I believe it to be particularly pertinent in mental disorder, how do we avoid the loss of the individual in population level statistical data?
The nature of mental disorder
Psychiatric phenomena are, by their very nature, subjective experiences. That is – an experience unique and ultimately appreciable only to the individual having the experience. Our interpretation of experiences are informed by our personal histories, previous psychological and social experiences. As such, each experience and our interpretation of it is likely unique and will represent a complex interaction between stimulus and our interpretation of that stimulus. This description can be applied equally to all experiences, but is particularly relevant to the experience of mental disorder.
I feel that one possible explanation for the experience of psychiatric phenomena is as a representation of the mind’s efforts to deal with stimuli and psychic experience. I think of defence here, a means to prevent the person becoming overwhelmed by experience. This account is controversial however and would not be a description shared by all psychiatrists.
Recovery IN Mental Disorder
Recovery from physical disorder is generally accepted as being a remission of distressing symptoms and resolution of function. Given what I have said about the nature of mental disorder as individual and subjective is this description adequate to describe recovery in mental disorder?
The “Recovery movement” emerged from the US in the 1990s, partly as a successor to the Psychiatric Survivor networks that emerged at the time of deinstitutionalisation in the 70s – 80s. The movement began to propose the idea of Personal Recovery – that is recovery defined, not by clinical measurement, but by the individual’s experiences. Through this lens recovery in mental disorder becomes more than symptom resolution – it becomes an evolving experience, a journey, survival in the face of trauma and suffering. The individual’s recovery priorities, and goals, must be respected lest we risk diminishing them as a person through the application of inappropriately pathologising labels.
Researching mental disorder
How then do we adequately represent this individual, subjective, nature of mental disorder. One possible answer lies in the application of qualitative research methods, which can allow some appreciation of subjective personal experience and learn from it. This leads me onto my own research, focussing on individual experiences of personal recovery and mental disorder.
My own research background began with a Masters in research and clinical chemistry. Following this I went onto study clinical medicine, where I experienced an introduction to the practice of evidence based medicine. I was drawn to psychiatry though, likely through some deep seated neurosis of my own, and after initial general medical training moved into full time psychiatric training.
More recently I have been lucky enough to be awarded a research fellowship that allows me to take time out from clinical practice to complete a discrete piece of research. I hope to focus on the experience of those who have received a personality disorder diagnosis and receive care in either community or secure settings.
My personal interest lies around the boundaries between society and mental disorder and the interactions between varying disciplines – psychiatry, psychology and sociology. I choose to focus on personality disorder as I believe this represents the very edge of this interaction. By focussing on the interaction at this crossover point I believe we can better inform our understanding, not just of personality disorder, of other mental disorders including the psychotic and affective disorders.
I’ve attached the slides to accompany the talk here – Psychiatry paradigm
Any comments / suggestions? Please share link around it would be great to get a conversation going – even if it’s just to tell me how wrong I am.