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Evidence-based Psychiatry: Searching the literature and Appraising the evidence

Evidence-based Psychiatry: Searching the literature and Appraising the evidence. Diana J. Cunningham, MLS, MPH, AHIP Associate Dean and Lillian Hetrick Huber Endowed Director, Health Sciences Library, New York Medical College April 9, 2014 Metropolitan Hospital . Today’s Agenda.

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Evidence-based Psychiatry: Searching the literature and Appraising the evidence

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  1. Evidence-based Psychiatry: Searching the literature and Appraising the evidence Diana J. Cunningham, MLS, MPH, AHIP Associate Dean and Lillian Hetrick Huber Endowed Director, Health Sciences Library, New York Medical College April 9, 2014 Metropolitan Hospital

  2. Today’s Agenda 1. Concepts: • Evidence-based medicine • Evidence-based psychiatric practice • Systematic Review • Levels of evidence: hierarchy of methodologies • 2. Systematic review process • 3. Applying the process & mapping to the literature • 4. Finding the evidence: Today’s case • 5. So what do we know?

  3. Today’s Objective: • By the end of this session, participants will be able to assess levels of evidence for a clinical psychiatric case and discuss examples from the literature

  4. What does it mean: enough evidence? • In clinical decision-making there is NEVER enough evidence! • Concepts: • Evidence-based medicine: • Distinguish stronger evidence from weaker evidence • Appraise critically the available evidence and balance the benefits and risks • Evidence-based psychiatric practice: • Focuses on broader care of patients; more complicated patients with less precise diagnoses, co-morbidities and treatment over time. • Gray, “Psychiatric clinical practice is not always evidence-based.” • Goal: to be aware of the evidence in one’s practice!

  5. Systematic Review Sample flow chart

  6. Apparent Life Threatening Events (ALTE) • ALTE Search Methodology: September 2013 • Diana Cunningham • Actual MyNCBI Search: • ((alte AND ((infant[MeSH]))) OR (altes AND ((infant[MeSH]))) AND ((infant[MeSH]))) OR ((apparent life threatening events AND ((infant[MeSH]))) OR (apparent life threatening event AND (infant[MeSH]))) OR (apparent life threatening event* AND ((infant[MeSH]))) AND ((infant[MeSH]))) OR ((life threatening events AND ((infant[MeSH]))) OR (life threatening event AND ((infant[MeSH]))) OR (life threatening event* AND ((infant[MeSH]))) AND ((infant[MeSH]))) OR ((near miss sids AND ((infant[MeSH]))) OR (near miss sudden infant death syndrome AND ((infant[MeSH]))) AND ((infant[MeSH]))) OR ((aborted crib death AND ((infant[MeSH]))) OR (aborted sudden infant death syndrome AND ((infant[MeSH]))) OR (aborted sids AND ((infant[MeSH]))) OR (aborted cot death AND ((infant[MeSH]))) AND ((infant[MeSH]))) AND ((English[lang]) AND (infant[MeSH]))

  7. Reviewing process

  8. Critical Appraisal: Is it high quality? • Are the results valid? • Did the review explicitly address the clinical question? • Was the search for relevant studies detailed and exhaustive? • Were the primary studies of high methodological quality? • What are the results? • What are the overall results of the review • Selection or inclusion/exclusion criteria • Comparability: randomized or not • Validity of evaluation instrument • Data-analysis • Can I apply the results to my patient? • But must be relevant to your patient or it doesn’t matter!

  9. Drilling Down for Evidence Value = (Relevance + Validity) / Time Grundage KK, Slawson DC, & Shaughnessy AF. When less Is More: A practical approach to Searching for evidence answers. J Med Libr Assoc 2002 July; 90(3): 298-304

  10. Evidence Pyramid: A Hierarchy of Methodologies

  11. Grades or Levels of Evidence is now included in various resources (e.g. Dynamed)f Evidence for the Purported Quality of Study Design.L Concato J et al. N Engl J Med 2000;342:1887-1892.

  12. Levels of Evidence

  13. Peer-Reviewed resources Bread and butter Pre-appraised Cochrane (in PubMed) UpToDate Dynamed Clinical Evidence National Guidelines Clearinghouse (AHRQ) • PubMed (see clinical queries option) • PsycINFO • Psychology and Behavioral Science Collection • Scopus

  14. And now: Search the literature • Goal: be aware of the evidence on which one’s practice is based, the soundness of the evidence, and the strength of interference that the evidence permits: • Formulate the relevant (clinical) question • Thorough search of the literature for answers pertaining to the question • Critically appraising the evidence for validity and importance • Apply results to your patient • Assess the outcome

  15. NYMC health Sciences Library

  16. The library barcode is your key to access… Get your barcode at the library as soon as possible for: • Remote access to online databases and journals • Borrowing privileges and access to the library. To obtain a barcode, complete form on the library’s web page or visit the Access Services Desk in the Library.

  17. Our Case Patient is a 37 year old Caucasian woman with schizophrenia. She has been a smoker since she was 9 years old. She currently coughs so badly she can barely speak and has expressed the desire to quit smoking. You have read something in the literature about the use of Wellbutrin. You want to look at the evidence in the literature.

  18. EBM Process

  19. Fresno Test Model:

  20. PICO • Patient • Intervention • Comparison • Outcome In (this type of patient), does (therapy A) vs (therapy B or control) (have a certain desired outcome)?

  21. ResourcesWhich databases:Which resourcessearch engineswould be most useful to find an answer to questions like these? 

  22. Search Strategy • Combination of terms/keywords/headings arranged with Boolean operators AND, OR, and NOT • “use quotes for indexed phrases” • Iterative process: • Do search – does it need broadening or narrowing? • To narrow – AND ; To broaden – OR • Look for MeSH terms and synonyms

  23. PubMed “Clinical Queries”

  24. PubMed Clinical Query

  25. PubMed Mesh Search

  26. PubMed Mesh and Keywords

  27. The evidence?

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