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APA, NAMI, NMHA, and evidence-based behavioural medicine: a comment
  1. R M Kaplan1,
  2. B Spring2,
  3. K Davidson3
  1. 1University of California, Los Angeles, CA, USA
  2. 2University of Illinois, Chicago, IL, USA
  3. 3Columbia University, New York, NY, USA

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    In February of 2005, The American Psychiatric Association (APA), National Alliance for the Mentally Ill (NAMI), and the National Mental Health Association (NMHA) released a statement publicly criticising the use of evidence-based research reviews for policy decisions affecting patients. Further, they argued against the use of evidence-based standards to guide reimbursement for healthcare services. We reviewed the statement and are concerned that many of the arguments are incorrect or misleading. In this note, we offer our responses by reproducing quotes from the APA-NAMI-NMHA statement and commenting on the merits of the arguments.

    CLINICAL JUDGMENT AS EVIDENCE

    The statement suggests that clinical experience should be given great weight in evidence-based decisions. The statement argues:

    “… true evidence-based approaches marry all available and appropriate scientific research with clinical experience to ensure treatments lead to the best possible outcomes.”

    We agree that clinical expertise is essential to discern which treatments supported by scientific evidence best match the needs and preferences of particular patients. In the best and most widely quoted definition of evidence-based medicine, Eddy states “Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values.”1 However, clinical judgment is known to vary2 even among experts. Dr Eddy reports widely divergent estimates of breast cancer implant rupture rates by 58 experts (around 50% of experts estimate a 10% or lower implant rupture rate and 20% estimate a 75% or higher rupture rate with the rest scattered in between); he has reported similar findings for experts’ judgment in other health conditions.

    One of the reasons that evidence-based guidelines have come to replace strictly clinical judgment is that there is substantial evidence for regional variation in the application of medical care.3–5 For example, Medicare spends nearly twice as much for each Southern California recipient in comparison to each recipient in …

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