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In many places, psychiatrists can be a scarce resource, so when you track one down, you want to get the most out of them. Unfortunately, psychiatrists do not come with operating instructions!  A key use of a psychiatrist is to make a through assessment of mental health and from that put together a treatment plan with you. Hopefully this guide will assist in getting the most use from your psychiatrist.

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A thorough assessment leading to an accurate diagnosis and formulation is essential before planning treatment (See article on Diagnosis in Psychiatry).  This will probably take at least one meeting and is really an ongoing process. With as good an understanding as possible of the health problem and a good formulation established, the options for treatment can be explored.

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Choosing a treatment involves making a prediction on what the most helpful step to take is, and as someone once said, “it is difficult to make predictions, particularly about the future”.[i]

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A previous article describes the principles of treatment planning and Evidence Base Medicine (EBM) .  Below is an outline of the practical questions that your psychiatrist will have in mind as well as a suggested process to use EBM principles in decision making. In the spirit of shared decision making, sometimes a gentle prompt from you, a friend, or family member, may help the discussion along.

 

Is it best to start treatment or not?

 

This is often the first, and sometimes most difficult, question. To answer it requires a good understanding of the options available, a careful “cost/benefit” analysis of those options and how these fit with the values and priorities of the patient. Sometimes watchful waiting is the best option as many mental health problems will resolve without specific treatment. Sometimes the best “treatment” may be not particularly psychiatric, such as lifestyle changes, changing social circumstances or improving an aspect of physical health.

 

Should we use the same treatment as last time?

 

Many mental disorders will improve or resolve completely with treatment, though there is a tendency for them to flare up again at some point in the future. After a thorough assessment to check that it is the same disorder which has come back, the first question about treatment is often “what worked last time?”. It makes sense to go to whatever has worked in the past unless the circumstances or preferences of the patient have changed, there were problematic side effects of the treatment last time, there are better treatment options now available or what was helpful before is not now available.

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If there have not been any treatments before, then the task for the doctor and patient is to decide on the best options from the range of possibilities. Discussing the pros and cons of the most promising options and exploring the person’s values, preferences and priorities leads to the right choice. This is the essence of evidence-based medicine.[ii]

 

Are there reliable guidelines on which treatments to consider?

 

Organisations such as Medical Colleges or Associations, and government agencies develop and publish guidelines for different health problems. These pull together research studies and weigh them up with the expert opinion of the guideline authors. Inevitably, guidelines are vulnerable to the biases of the authors or the publishing organisation and often raise debate in the medical profession about whether some of the guidance is correct. By nature, guidelines are broad and apply to the “average patient most of the time”. These are often the “go-to” starting point for a psychiatrist when thinking about choice of treatment. However, it is important to remember that these are “a guide” only, not a set of rules, and to carefully consider the unique characteristics, preferences and circumstances of the patient when deciding on treatment choice.

 

Is there a systematic review that can help us decide?

 

A “systematic review” pulls together all the studies that have been done relevant to answering a particular research question and that meet clearly defined criteria. The studies included in a review are usually “randomised, controlled trials” (RCT) which are regarded as the gold standard of research. The strength of an RCT is that it is possible to reduce biases which could produce false results. A well-done RCT can give a reliable answer to a research question, such as is a particular treatment better than a placebo treatment. There may be many relevant studies and only those that meet stringent quality standards are included, so some research papers are discarded. A powerful statistical process called “meta-analysis” can combine information from different studies making results more reliable.

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A systematic review published in the Cochrane Library (https://www.cochranelibrary.com/) can be relied on to be of extremely high quality and may well be helpful in reaching the right treatment decision. As well as being very comprehensive these reviews helpfully have summaries written in plain English.

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Are there individual studies we should consider?

 

Sometimes there is not a useful guideline or systematic review either because a relevant one has not been done, or those published are a few years old and there has been other important research published in the meantime.

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Finding and analysing individual studies can be taxing. So, you may notice the demeanour of your psychiatrist change to a slightly pained expression and some sweat develop on their brow. They now must switch from relatively easy “recall the guideline” or “check the Cochrane Library” mode to the more laborious and mentally challenging “analyse the research” mode! Undoubtedly, there will be published studies relevant to the decision that you need to make, though there is a huge range in quality and relevance of these which must be assessed, and that is hard work and takes time.

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Constructing a clear question you want to answer using a “PICOT” model – patient, intervention, comparator, outcome, time – is a useful starting point. For example, “For a 35-year-old man with obsessive compulsive disorder (P) is cognitive behavioural therapy (I) more effective than antidepressant medication (C) in reducing symptoms and improving quality of life (O) after twelve months (T)?”.

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Which studies are most relevant?

 

Once you have put together your question, the next step is to find studies which may help find the answer. This is done by searching through online electronic databases of published research such as “Medline” which is accessed through PubMed (https://pubmed.ncbi.nlm.nih.gov/ ) or the Cochrane Library collection of trials.

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It is quite likely that you will be different in some way from the group of people included in the research study and a judgement must be made whether you resemble the people studied closely enough for the results to be relevant to you. For example, is a study of the effectiveness of a psychological treatment for Post-Traumatic Stress Disorder (PTSD) in male US Army Veterans between the ages of 20 and 65 useful when deciding on the best treatment for an 18-year-old indigenous Australian woman who has developed PTSD following a motor vehicle accident? Probably not. A trial of psychological treatments for PTSD in young Australian adults in the general population is likely to be much more helpful.

 

How reliable are the results and conclusions in these papers?

 

Once relevant papers have been found they must be assessed for quality. This is like the process carried out in putting together a systematic review though on a smaller scale and more personalised.  There are generally accepted ways of assessing the quality of research and how reliable the results and conclusions are. Well-done randomised controlled trials are the most reliable. Evidence from non-randomised trials is usually weaker and other types of research weaker still. The “GRADE” system is an established process to assess the quality of published research studies[iii]. Important factors in assessing quality are whether some biases in the research method, whether accidental or deliberate, have led to inaccurate results. The authors’ conclusions from their results must also be assessed for validity. It is not unusual for researchers to over-emphasise the findings they would like to have and play down the ones they do not – researchers are only human after all! It is more common for studies with positive findings to be published in scientific journals and negative ones to be left gathering dust in the researcher’s office, and such “publication bias” must be accounted for. A rigorous sifting of published research papers may lead to only one or two reliable ones being found, and sometimes none of high quality.

 

How much better is one treatment compared to the alternative?

 

Sometimes research can convincingly show that a treatment is better than nothing; a placebo, or an alternative treatment, but the difference is so small as to have no real benefit for a person’s health. Calculating the “number needed to treat” (NNT) to have one more person respond to a treatment compared to the alternative is a good way to estimate how much better one option is compared to another. The NNT is quoted in many reviews and papers. While this is a useful number to calculate, it is important to note what the treatment was compared to in the original research study. In clinical practice the decision is usually to start a particular treatment or not – we do not deliberately give out placebos! As there is often a large positive response to placebo in psychiatric disorders, a NNT quoted where the comparator was placebo rather than doing nothing will falsely underestimate the likelihood of a beneficial outcome.[iv] Conversely, if a treatment is compared to offering the patient nothing at all, the effect of treatment will be exaggerated as the people getting nothing won’t even have a placebo effect. This can lead to the intervention appearing effective, when it actually is purely placebo.

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What potential harm is associated each treatment option?

 

Many studies will look at possible side-effects of the different treatments or placebo. Comparing the frequency of different side effects and calculating a “number needed to harm” (NNH) gives an assessment of how likely it is that an unwanted effect will happen compared to if the person was given placebo or an alternative treatment. Most research papers will mention how many people withdrew from the study before the end. While this can be for many reasons, a comparison between the number of people opting out of the study who were on one treatment versus another can give an indication of how unpleasant or ineffective a treatment is. The ratio of NNT to NNH can be useful as this is often the type of decision made in practice when trying to decide whether on a cost-benefit basis it is worth proceeding with a particular treatment. It is important to think of potential harms broadly as some treatments such as spending time in hospital or having some therapies can cause harms which are not immediately apparent or easy to measure in research studies.

 

What are the costs of the different treatment options?

 

Cost involves not just the price of a medication, therapy sessions, or time in hospital, but also the cost of time away from productive work or study, and the “opportunity cost” of being unable to use the money and time which goes on treatment on something else. It is possible that spending money on something such as a gym membership, travel to visit a family member or paying off a debt may have a better effect on mental health than a formal “treatment”. Looking at the costs broadly often leads to better treatment decisions.

 

What do we know about long term benefits and harm?

 

Most research trials of treatment are over a few weeks or months. As health problems often go on for longer or come and go over the course of a lifetime, there may be little research to guide long term treatment decisions. Usually more is known about treatments which have been around for a long time, both in terms of long-term benefits of treatment and any long-term harm.

 

 

Without doubt your psychiatrist will have your best interests at the forefront of their mind, though they are only human and so vulnerable to the promise of magic potions, secret spells, and rituals. They can be influenced by persuasive pharmaceutical companies, enthusiasts for the latest fashion in psychotherapy or even unscrupulous snake-oil salesmen, so a thoughtful process including critical exploration with them of the strength of scientific evidence behind the claims of a treatment is essential.

 

One Minute Summary

 

• A thorough and reliable assessment is necessary before planning treatment

 

• Deciding on treatment is making a prediction of the most helpful thing to do – and predictions about the future are difficult as we are all unique!

 

• Using high quality scientific research and a thoughtful process incorporating patient values and clinical judgement can improve the accuracy of predictions and so lead to better treatment. This is the essence of evidence-based medicine.

 

• Guidelines published by medical authorities are a good starting point when considering treatment options.

 

• Critical analysis of the research is important, though is hard work.

 

• Progress in medical treatment by following a scientific method is slow. Humans are often impatient and so vulnerable to optimistic claims made about new treatments which may have no, or very weak, evidence for effectiveness.

 

• Carefully consider the broad costs of treatment.

 

• There are often powerful forces influencing doctors and patients about which treatment to follow, whether from drug companies, promoters of the latest fashion in psychotherapy, internet influencers, the popular media, or politicians. Navigating through the sea of information and dis-information without being blown off course by such influences before reaching solid, objective ground on which to make decisions can be very difficult – but is achievable!

 

 

[i] Variously attributed to Mark Twain, Yogi Berra, and several others

[ii] Sackett DL Rosenberg WM Gray JA Haynes RB Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ. 1996;3127023:71-72.

[iii] For information about the GRADE system read What is GRADE? | BMJ Best Practice

[iv] Practising evidence-based medicine in an era of high placebo response: number needed to treat reconsidered. Roose SP, Rutherford BR, Wall MM, Thase ME, Br J Psychiatry. 2016 May; 208(5):416-20