Evidence-based Practice in Psychology (EBPP) Lindsey Cohen

Evidence-based Practice in Psychology EBP in Medical Fields EST vs. Clinical Expertise Public Policy/ Reimbursement Quality and Accountability

APA Policy Statement on Evidence-Based Practice in Psychology (2005) “Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.”

APA Policy Statement on Evidence-Based Practice in Psychology (2005) “Evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.”

The EBP Model- The 3-Legged Stool Best available research evidence EBP Patient preferences and values Clinical expertise In integrating EBP into our training, we rely on Sackett et al (2000) tripartite model: Best available research evidence – clinicians must avail themselves of the best available research evidence when making treatment decisions. RCT is still the gold standard but other evidence may be considered as well, for example effectiveness data. Patient preference and values – considering role of patients’ individual characteristics in treatment; includes a consideration of diversity issues as well as the need to involve the patient fully in treatment planning including analysis of the chances they will benefit or not from the evidence-based approach (using quantitative presentations when possible). Clinical expertise - Advanced clinical skills to diagnose, assess, and treat clients. How does one translate the best available research evidence, which may have been developed for the average or a prototypical client, for use with a particular patient?

Continuum of care Nomothetic (decisions based on disorders, guidelines, treatment manuals, ESTs) Evidence-based practice Idiographic (decisions based on individual patients and circumstances)

The EBP Model – Best Available Research Evidence Adopt a scientific view of clinical psychology Knowledge of clinical research design and methods Strategies for accessing best available research Ability to evaluate relevant evidence

Best Available Research Evidence Creator Best available research evidence Synthesizer C o n s u m e r

Research – Evidence Creator Design, conduct, and report research The 12 International Committee of Medical Journal Editors journals (e.g., JAMA, The Lancet) agreed to only accept RCTs if they registered in the public registry prior to recruitment (e.g., http://www.who.int/ictrp/en/). Why? Randomized Controlled Trials (RCTs) and CONSORT http://www.consort-statement.org/?o=1011 . Why?

Example CONSORT Flow Chart

Example CONSORT Checklist

Research – Synthesizer Locate, appraise, and synthesize research Systematic reviews – standardized criteria Meta-analyses P.I.C.O. Population, Intervention, Comparison, Outcome Inclusion, exclusion, databases searched (e.g., psycINFO, MEDLINE, EMBASE), dates of search, search terms, etc.

Research – Consumer Access, appraise, and integrate into practice Performing the 5 A’s (Strauss et al., 2005) Ask the question (e.g., PICO) Acquire the evidence Appraise the evidence Apply the results Assess the outcome

Medical/Health Database – Acquiring the evidence Research Literature PSYCINFO EMBASE Cochrane / others* MEDLINE *Note that Cochrane and some other databases are not linked to PsycINFO .

Acquiring the evidence – Smart searches A variety of search engines and databases are available or are being created to facilitate EBP, especially in medicine www.tripdatabase.com, www.ahrq.gov, http://sumsearch.uthscsa.edu/, www.york.ac.uk/inst/crd/crddatabases.htm, www.guideline.gov, www.cochrane.org

Appraising the Evidence

The EBP Model – Patient Preferences and Values Therapy is a collaborative endeavor, shared-decision making Knowledge of specific diverse groups Ability to ascertain patient values and preferences Respond effectively to patient preferences and values Patient preferences and values In integrating EBP into our training, we rely on Sackett et al (2000) tripartite model: Best available research evidence – clinicians must avail themselves of the best available research evidence when making treatment decisions. RCT is still the gold standard but other evidence may be considered as well, for example effectiveness data. Patient preference and values – considering role of patients’ individual characteristics in treatment; includes a consideration of diversity issues as well as the need to involve the patient fully in treatment planning including analysis of the chances they will benefit or not from the evidence-based approach (using quantitative presentations when possible). Clinical expertise - Advanced clinical skills to diagnose, assess, and treat clients. How does one translate the best available research evidence, which may have been developed for the average or a prototypical client, for use with a particular patient?

The EBP Model – Clinical Expertise Common factors/non-specific skills Awareness of limits of clinical judgment Relationship building Assessment and diagnostic skills Ability to implement treatments Integration of EST with client characteristics Clinical expertise In integrating EBP into our training, we rely on Sackett et al (2000) tripartite model: Best available research evidence – clinicians must avail themselves of the best available research evidence when making treatment decisions. RCT is still the gold standard but other evidence may be considered as well, for example effectiveness data. Patient preference and values – considering role of patients’ individual characteristics in treatment; includes a consideration of diversity issues as well as the need to involve the patient fully in treatment planning including analysis of the chances they will benefit or not from the evidence-based approach (using quantitative presentations when possible). Clinical expertise - Advanced clinical skills to diagnose, assess, and treat clients. How does one translate the best available research evidence, which may have been developed for the average or a prototypical client, for use with a particular patient?

The EBP Model Evidence-based practice is the successful integrations of these three competencies EBP In integrating EBP into our training, we rely on Sackett et al (2000) tripartite model: Best available research evidence – clinicians must avail themselves of the best available research evidence when making treatment decisions. RCT is still the gold standard but other evidence may be considered as well, for example effectiveness data. Patient preference and values – considering role of patients’ individual characteristics in treatment; includes a consideration of diversity issues as well as the need to involve the patient fully in treatment planning including analysis of the chances they will benefit or not from the evidence-based approach (using quantitative presentations when possible). Clinical expertise - Advanced clinical skills to diagnose, assess, and treat clients. How does one translate the best available research evidence, which may have been developed for the average or a prototypical client, for use with a particular patient?

The EBP Model Evidence-based practice is the successful integrations of these three competencies Clinical decisions should be guided by all three areas CD In integrating EBP into our training, we rely on Sackett et al (2000) tripartite model: Best available research evidence – clinicians must avail themselves of the best available research evidence when making treatment decisions. RCT is still the gold standard but other evidence may be considered as well, for example effectiveness data. Patient preference and values – considering role of patients’ individual characteristics in treatment; includes a consideration of diversity issues as well as the need to involve the patient fully in treatment planning including analysis of the chances they will benefit or not from the evidence-based approach (using quantitative presentations when possible). Clinical expertise - Advanced clinical skills to diagnose, assess, and treat clients. How does one translate the best available research evidence, which may have been developed for the average or a prototypical client, for use with a particular patient?

Putting EBP into Practice Imagine you are a busy clinical student conducting therapy in the clinic. You are working with a mom who was previously but not currently depressed. She states she is pregnant with number two and is worried about postpartum depression. She wants help to prevent it. You let her know that you will provide additional information next session.

What do you do? Ask your advisor, consult with others, and base your response on your clinical experience? Not likely to reflect current scientific evidence Google search Many websites, but the information might be inaccurate and outdated PsycINFO and Medline Overwhelming and conflicting information

The EBP Answer Use the 5 A’s

Ask Clinically-Relevant Questions Pose background and foreground questions Background questions Knowledge base – Who, what, where, or how followed by a condition or situation How does postpartum depression differ from other depression? What are the risk factors for postpartum depression?

Clinically-Relevant Questions (cont.) Foreground questions – PICO format P (Patient group) I (Intervention) C (Comparison Group) O (Outcome measures) In a woman with a history of depression (P), is there evidence that CBT, delivered while pregnant (I), will be more effective than no prenatal treatment (C) in reducing postpartum depression (O)?

Search for the Best Research Evidence Focus on the top of the pyramid – systematic reviews if available A TRIP (www.tripdatabase.com) search using “postpartum depression” revealed 334 records that can be sorted by type of article, question, or specialty. Second systematic review, a cochrane review, concludes that there is no evidence that psyc interventions prevent postnatal depression, but support for at-risk mothers might be helpful

How does this fit with our client? Sort TRIP search by etiology, risks factors based on 2 meta-analyses and studies with 10,000 other women: Depression and anxiety during pregnancy, low social support, prior psychopathology, poor marital relationship A TRIP search on antidepressants leads to a Cochrane review, which concludes that evidence is weak for meds to prevent later postpartum depression

Integrating research with client Given she has only 1 risk factor, there is limited evidence that psychological or pharmacological interventions would prevent postpartum depression. However, she should watch for depression after birth and CBT or interpersonal treatment should be helpful. Effectiveness of group CBT, light therapy, and psychoeducation for postpartum depression are unknown

Best available research evidence Patient preferences and values The EBP Model Opposed to meds; prefers interpersonal therapy; insurance pays for 10 sessions; previously depressed Limited evidence for preventative interventions; risk factors; monitor after birth; CBT or interpersonal for postpartum depression Best available research evidence EBP Patient preferences and values Clinical expertise Appropriate assessment; ability to perform treatment; integrate research and clinical evidence