The anomalies of evidence-based medicine in psychiatry: time to rethink the basis of mental health practice

Purpose - Evidence-based medicine (EBM) is a technical and scientific paradigm in clinical practice that has delivered major improvements in the outcome of care in medicine and surgery. However, its value in psychiatry is much less clear. The purpose of the paper is thus to examine its value by subjecting empirical evidence from EBM to a conceptual analysis using the philosophy of Thomas Kuhn. Design/methodology/approach - The authors examine evidence drawn from meta-analyses of RCTs investigating the efficacy of specific treatments for depression in the form of antidepressant drugs and CBT. This shows that the non-specific aspects of treatment, the placebo effect and the quality of the therapeutic alliance as seen by the patient, are more important in determining outcome than the specific elements (active drug, specific therapeutic elements of CBT). Findings - Using the philosophy of Thomas Kuhn, it is shown that these non-specific and non-technical elements are anomalies that indicate that the technological paradigm in the treatment of depression is fundamentally flawed. Practical implications - Non-specific elements of mental health care are essential in fostering hope, trust and meaning. They constitute non-technical factors that are central to the concept of caring, and vital for recovery, and which resonate strongly with the growth of survivor and user-led systems of support for people who experience distress and madness. As such they pose a major challenge to scientific psychiatry and mental health services based in this. The analysis has major implications for the primacy of the natural sciences in the education and training of those involved in mental health work, and demonstrates the importance of an open debate about the value of the scientific imagination in mental health work. Social implications - This paper is important because it supports user-led self-defined notions and understandings of recovery, and does so using a philosophical conceptual analysis. Originality/value - This conceptual analysis is highly original. To the authors' knowledge no one has subjected EBM to a detailed conceptual analysis using the ideas of Thomas Kuhn.