Evidence-based mental health policy: a critical appraisal

Background. Arguments for and against evidence-based psychiatry have mostly centred on its value for clinical practice and teaching. Now, however, use of the same paradigm in evaluating health care has generated new problems. Aims. To outline the development of evidence-based health care; to summarise the main critiques of this approach; to review the evidence now being employed to evaluate mental health care; and to consider how the evidence base might be improved. Method. The following sources were monitored: publications on evidence based psychiatry and health care since 1990; reports of randomised trials and meta-analytic reviews to the end of 2002; and official British publications on mental health policy Results Although evidence-based health care is now being promulgated as a rational basis for mental health planning in Britain, its contributions to service evaluation have been distinctly modest. Only 10% of clinical trials and meta-analyses have been focused on effectiveness of services, and many reviews proved inconclusive. Conclusions. The current evidence-based approach is overly reliant on meta-analytic reviews, and is more applicable to specific treatments than to the care agencies that control their delivery. A much broader evidence base is called for, extending to studies in primary health care and the evaluation of preventive techniques.