Résumés
Résumé
Le discours psychiatrique contemporain dominant repose principalement sur un paradigme médico-technologique où la souffrance mentale est conceptualisée comme un « mécanisme défectueux » qui nécessite une « réparation » grâce à l’arsenal médical. Dans ce contexte, l’evidence-based medicine (EBM) a donc été largement adopté par la psychiatrie à la fin des années 90. L’EBM est une proposition qui vise à influencer et même légiférer la prise de décisions cliniques en mettant de l’avant l’idée d’une hiérarchie des évidences, où le savoir tiré d’essais contrôlés randomisés (ECR) et de méta-analyses a préséance sur les informations tirées d’autres sources. Ainsi, comme l’EBM favorise ces outils de création de savoir (ECRs et méta-analyses) il en découle que le savoir qui compte véritablement dans le paradigme EBM est celui qui est mesurable et spécifique ; deux conditions préalables nécessaires pour l’utilisation même de ces outils. En conséquence, l’EBM diminue la valeur et va même jusqu’à ignorer d’autres formes d’évidences, de savoir et de justifications pour la prise de décisions cliniques. Du point de vue éthique, le concept EBM soutient que la « bonne chose à faire » est d’appliquer le savoir produit par l’EBM dans le contexte clinique. Les autres formes de savoir pouvant être impliquées dans la prise de décisions cliniques, mais qui ne peuvent pas être étudiées via l’EBM, sont dévalorisées d’un point de vue éthique. La littérature révisée et explorée ici considère donc que l’EBM est mal adapté à la réalité de la pratique psychiatrique. L’EBM ne peut pas, par définition, prendre en compte les spécificités de la discipline, notamment pour ce qui est des diagnostics psychiatriques ; leur complexité rend les évidences produites par l’EBM d’une validité questionnable. Le concept ne peut pas non plus tenir compte des spécificités des thérapeutiques psychiatriques. Les facteurs thérapeutiques non spécifiques, ceux discrédités par l’EBM, sont cruciaux pour les soins de santé mentale. Également, les observations portant sur des aspects de l’esprit, sur des expériences subjectives, ne sont que bien incorrectement traduites en résultats statistiques, mesurables et spécifiques. Ces observations amènent le présent essai à considérer qu’il serait peut-être préférable pour la psychiatrie, de rejeter la « hiérarchie des évidences » de l’EBM, et de développer son propre « système des savoirs ». Celui-ci devrait prendre en compte la position épistémologique unique de la psychiatrie, où subjectivité, contextes, et valeurs pourraient occuper de façon légitime la place qui leur revient dans la prise de décisions cliniques en psychiatrie. Bien qu’une alternative à l’EBM en psychiatrie n’ait pas encore été établie, la littérature, et ce papier pointent vers l’idée d’un « système des savoirs » plus flexible que ce qu’offre l’EBM en termes épistémologiques, où les aspects éthiques reliés à la discipline, incluant l’éthique du savoir, l’éthique de « ce qui compte comme évidence », revêtent une importance cruciale.
Mots-clés :
- psychiatrie basée sur les évidences,
- épistémologie,
- éthique,
- données probantes
Abstract
Current mainstream psychiatric discourse and practice rely mostly on a dominant technological paradigm where mental distress is understood as a “faulty mechanism” which needs “fixing” through medical means. As such, evidence-based medicine (EBM), a recent medical concept which encourages technological knowledge and hence technological understanding and interventions, was embraced by contemporary psychiatry. EBM is a proposition which seeks to regulate clinical decision-making by putting forth the idea of a hierarchy of evidence, where information yielded from randomized controlled trials (RCTs) and meta-analyses have definite precedence over other forms or sources of information. Thus, because EBM favors these evidence-producing tools, RCTs and meta-analyses, it purports that the knowledge that counts is that which is measurable and specific; necessary conditions for its detection by such tools. In doing so, EBM devalues and arguably even ignores other forms of evidence and warrants for clinical decision-making. From the standpoint of ethics, it purports that the “right” thing to do is to apply the evidence produced by EBM in a clinical setting. Other forms of evidence and relevant information regarding clinical decision-making which cannot be produced or measured by EBM are ethically devalued. Reviewed literature in the field of philosophy of psychiatry thus argues that EBM is ill-suited for psychiatry. It has a reductive view of the epistemological and related ethical issues regarding psychiatric practice. It cannot, by design, account for the specificities of psychiatry, notably in terms of diagnoses; their complexity easily renders the evidence created by EBM of questionable validity. It also cannot account for the specificities of psychiatric therapeutics. Outcomes related to the mind are incorrectly translated into specific and measurable results, and amongst other points, non-specific therapeutic factors, the ones discredited by EBM, are core to mental health care: nonsense. This leads the current critical review to consider that psychiatry would perhaps benefit from the development of its own evidentiary framework, taking into account its unique epistemological position, where subjectivity, context and values cannot be downplayed in the hierarchy of evidence, in the hierarchy of warrants for decision-making. This discussion inevitably raises the question of the object of study of psychiatry, which appears to be somewhat different than that of medicine. It also forces a conversation on the goals of psychiatry; they appear more complex than the achievement of measurable and specific health outcomes. Although a definite alternative to EBM in psychiatry has yet to be established, the literature, and this paper, point towards the idea of a more flexible evidentiary framework for psychiatry, one where ethical issues, including the ethics of what counts as evidence, should be of crucial importance.
Keywords:
- evidence-based psychiatry,
- epistemology,
- ethics
Parties annexes
Bibliographie
- APA, A. P. A. (2013). Diagnostic and statistical manual of mental disorders : DSM-5. Washington, D. C. : American Psychiatric Association.
- Bolton, D. (2008a). The epistemology of randomized, controlled trials and application in psychiatry. Philosophy, Psychiatry, & Psychology, 15(2), 159-165.
- Bolton, D. (2008b). What is mental disorder?: an essay in philosophy, science, and values. Oxford, R.-U. : Oxford University Press.
- Bracken, P. et Thomas, P. (2013). Challenges to the Modernist Identity of Psychiatry: User Empowerment and Recovery (Chapter 11). In M. D. KWM Fulford, Richard G.T. Gipps, George Graham, John Z. Sadler, Giovanni Stanghellini, and Tim Thornton (Ed.), The Oxford Handbook of Philosophy and Psychiatry (pp. 123-138). Oxford, R.-U. : Oxford University Press.
- Bracken, P. et Thomas, P. (2005). Postpsychiatry. Oxford, N. Y. : Oxford University Press.
- Buetow, S.et Kenealy, T. (2000). Evidence-based medicine: the need for a new definition. Journal of Evaluation in Clinical Practice, 6(2), 85-92.
- Djulbegovic, B., Guyatt, G. H. et Ashcroft, R. E. (2009). Epistemologic inquiries in evidence-based medicine. Cancer Control, 16(2), 158-168.
- EBMWG, E.-B. M. W. G. (1992). Evidence-based medicine. A new approach to teaching the practice of medicine. Jama, 268(17), 2420.
- Falkum, E. (2009). Phronesis and Techne: The Debate on Evidence-Based Medicine in Psychiatry and Psychotherapy. Philosophy, Psychiatry, and Psychology, 15(2), 141-149.
- Fernandez, A., Sturmberg, J., Lukersmith, S., Madden, R., Torkfar, G., Colagiuri, R. et Salvador-Carulla, L. (2015). Evidence-based medicine: is it a bridge too far? Health Res Policy Syst, 13, 66.
- Foucault, M. (1989). Madness and civilization : a history of insanity in the Age of Reason. London, R.-U. : Routledge.
- Fulford, K. B. (2008). Values-based practice: from the real to the really practical. Philosophy, Psychiatry, and Psychology, 15(2), 183-185.
- Fulford, K. W. (2011). The value of evidence and evidence of values: bringing together values-based and evidence-based practice in policy and service development in mental health. J Eval Clin Pract, 17(5), 976-987.
- Geanellos, R. et Wilson, C. (2006). Building bridges: knowledge production, publication and use. Commentary on Tonelli (2006), Integrating evidence into clinical practice: an alternative to evidence-based approaches. Journal of Evaluation in Clinical Practice 12, 248–256. Journal of Evaluation in Clinical Practice, 12(3), 299-305.
- Geddes, J. (1996). On the need for evidence-based psychiatry. Evidence Based Medicine, 1(7), 199-200.
- Geddes, J. R. et Harrison, P. J. (1997). Closing the gap between research and practice. The British Journal of Psychiatry, 171(3), 220-225.
- Goldenberg, M. J. (2006). On evidence and evidence-based medicine: lessons from the philosophy of science. Social Science & Medicine, 62(11), 2621-2632.
- Gray, G. E. (2008). Concise guide to evidence-based psychiatry. Arlington, VA : American Psychiatric Publishing.
- Greenhalgh, T. (1999). Narrative based medicine in evidence-based world. Bmj, 318(7179), 323-325.
- Gupta, M. (2007). Does evidence-based medicine apply to psychiatry? Theor Med Bioeth, 28(2), 103-120.
- Gupta, M. (2009). Ethics and evidence in psychiatric practice. Perspect Biol Med, 52(2), 276-288.
- Gupta, M. (2011). Values-based practice and bioethics: close friends rather than distant relatives. Commentary on “Fulford (2011). The value of evidence and evidence of values: bringing together values-based and evidence-based practice in policy and service development in mental health”. J Eval Clin Pract, 17(5), 992-995.
- Gupta, M. (2012). Evidence-based medicine: we ought to practise it, but we still do not know why. J Eval Clin Pract, 18(5), 1111-1112.
- Gupta, M. (2014). Is evidence-based psychiatry ethical? Oxford, R.-U. : Oxford University Press.
- Guyatt, G. (1991). Evidence-based medicine. ACP J Club, 114, A16.
- Holmes, D. et Gagnon, M. (2008). Evidence to practice and practice to evidence: misunderstanding the epistemic incommensurability. A commentary on Isaac & Franceschi (2008). J Eval Clin Pract, 14(5), 663-664.
- Hopton, J. (2006). The future of critical psychiatry. Critical Social Policy, 26(1), 57-73.
- Lambert, M. J. (2013). Outcome in psychotherapy: The past and important advances.
- Levine, R., & Fink, M. (2003). The case against evidence-based principles in psychiatry. Medical Hypotheses, 67(2), 401-410.
- Loughlin, M. (2006). The future for medical epistemology? Commentary on Tonelli (2006), Integrating evidence into clinical practice: an alternative to evidence-based approaches. Journal of Evaluation in Clinical Practice 12, 248-256. J Eval Clin Pract, 12(3), 289-291.
- Maier, T. (2006). Evidence‐based psychiatry: understanding the limitations of a method. Journal of Evaluation in Clinical Practice, 12(3), 325-329.
- Markovà, I. S. et Berrios, G. E. (2012). Epistemology of psychiatry. Psychopathology, 45(4), 220-227.
- Meyer, A. et Lief, A. E. (1948). The commonsense psychiatry of Dr. Adolf Meyer: Fifty-two selected papers
- Möller, H.-J. (2012). How close is evidence to truth in evidence-based treatment of mental disorders? European Archives of Psychiatry and Clinical Neuroscience, 262(4), 277-289.
- Moller, H. J. et Maier, W. (2010). Evidence-based medicine in psychopharmacotherapy: possibilities, problems and limitations. Eur Arch Psychiatry Clin Neurosci, 260(1), 25-39.
- Moncrieff, J. (2008). The myth of the chemical cure. In The Myth of the Chemical Cure (pp. 217-224). London, R.-U. : Palgrave Macmillan.
- Moncrieff, J. (2009). A critique of the dopamine hypothesis of schizophrenia and psychosis. Harv Rev Psychiatry, 17(3), 214-225.
- Morstyn, R. (2013). Escaping the behavioural “spin” of evidence-based psychiatry: Merleau-Ponty's ontology of truth. Australas Psychiatry, 21(4), 311-314.
- Norcross, J. C., Beutler, L. E. et Levant, R. F. (2006). Evidence-based practices in mental health: Debate and dialogue on the fundamental questions. Washington, D.C. : American Psychological Association.
- ONU. (2007). Convention relative aux droits des personnes handicapées. (https://www.un.org/disabilities/documents/convention/convoptprot-f.pdf). Visité le 26 juillet 2020).
- Phillips, J. (2009). Introduction. In J. Phillips (Ed.), Philosophical Perspectives on Technology and Psychiatry (pp. 1-19). Oxford, R.-U. : Oxford University Press.
- Polychronis, A., Miles, A. et Bentley, P. (1996). Evidence-based medicine: reference? Dogma? Neologism? New orthodoxy? J Eval Clin Pract, 2(1), 1-3.
- Sackett, D. L., Rosenberg, W. M. C., Gray, J. A. M., Haynes, R. B. et Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn't. Bmj, 312(7023), 71-72.
- Sedgwick, P. (1982). Psycho Politics. New York, N.Y. : Harper & Row.
- Thomas, P., Bracken, P. et Timimi, S. (2012). The anomalies of evidence‐based medicine in psychiatry: time to rethink the basis of mental health practice. Mental Health Review Journal, 17(3), 152-162. doi:
- Thomas, P., Bracken, P. et Timimi, S. (2013). The Limits of Evidence-Based Medicine in Psychiatry. Philosophy, Psychiatry, and Psychology, 19(4), 295-308.
- Tonelli, M. R. (1998). The philosophical limits of evidence-based medicine. Academic Medicine, 73(12), 1234-1240.
- Tonelli, M. R. (2006). Integrating evidence into clinical practice: an alternative to evidence-based approaches. J Eval Clin Pract, 12(3), 248-256.
- Tonelli, M. R. (2009). Evidence-free medicine: forgoing evidence in clinical decision-making. Perspect Biol Med, 52(2), 319-331.
- Tonelli, M. R. (2010). The challenge of evidence in clinical medicine. J Eval Clin Pract, 16(2), 384-389.
- Upshur, R. E. 2006. “The complex, the exhausted and the personal: reflections on the relationship between evidence-based medicine and casuistry. Commentary on Tonelli (2006), Integrating evidence into clinical practice: an alternative to evidence-based approaches.”, Journal of Evaluation in Clinical Practice, 12: 281-8
- Wakefield, J. C. (1992). The concept of mental disorder: on the boundary between biological facts and social values. American Psychologist, 47(3), 373
- Williams, D. D. R. et Garner, J. (2002). The case against “the evidence”: a different perspective on evidence-based medicine. The British Journal of Psychiatry, 180(1), 8-12.