Concept Of Comorbidity Research Articles

Changes in renal function in patients with hypertension and chronic obstructive pulmonary disease according to retrospective analysis of medical records

Background. Hypertension determines both the social and economic component of the impact on the health of the population with a tendency to a significant increase in this pathology rate. Another common disease that can be prevented and treated is a chronic obstructive pulmonary disease (COPD). The concept of comorbidity implies the formation of relationships and interactions due to the common pathogenetic mechanisms, namely chronic inflammation, oxidative stress, and endothelial dysfunction. Hypertension is both a cause and a consequence of chronic kidney disease (CKD) and contributes to its progression. Patients with COPD have a higher risk of comorbidities. Aim. To study the dynamics of renal function and frequency of CKD development in patients with hypertension and COPD based on the retrospective analysis of case reports and outpatient medical records. Materials and methods. According to the criteria of inclusion and exclusion from the study, 188 patients were selected, which were divided into three groups by the clinical diagnosis: group 1 consisted of 64 patients with hypertension, group 2 — 58 patients with hypertension and chronic obstructive pulmonary disease, and group 3 — 66 patients with chronic obstructive pulmonary disease. The average age of patients with hypertension was 61.0 (57.0; 72.0) years, patients with hypertension and COPD — 62.3 (11.5), the average age of patients with COPD — 58.5 (55.0; 62.00). The physical examination, the laboratory tests of blood and urine were analyzed in all patients by studying the case reports and outpatient medical records. The obtained results were processed using biostatistical methods (Statistica v.6.1). Results. Important significance between the frequency of anemia in patients was not found, but there was a tendency to increase in anemia frequency in hypertensive patients — 14.1 % and in the comorbidity of hypertension and COPD — 8.6 %. The lowest incidence of anemia was recorded in patients with COPD and was 7.6 %. The level of total cholesterol in the respective groups did not differ statistically and was equal to 4.8 (4.2; 5.3), 4.7 (4.0; 5.4), and 5.3 (4.5; 5.9) mmol/l. The highest values ​​of total blood cholesterol were determined in patients with hypertension and chronic obstructive pulmonary disease. The highest level of blood creatinine was determined in patients with hypertension and COPD, and the lowest — in patients with COPD. Thus, the patients with hypertension had the lowest GFR and the patients with COPD had the highest one. Conclusions. COPD has a tightening effect on the renal function of patients with hypertension and leads to an increase in blood creatinine levels with statistical significance. Also, in the group of patients with hypertension and comorbid pathology, a higher incidence of anemia was registered than in the group of patients with COPD. But, in turn, the filtration function of the kidneys, which was determined by GFR, was the lowest in hypertension.

Are There Common Pathways for Eating Disorders and Female Sexual Dysfunction?

Sexuality and sexual dysfunctions are too often considered taboos in the clinical management of eating disorders. 1 Castellini G Lelli L Ricca V et al. Sexuality in eating disorders patients: etiological factors, sexual dysfunction and identity issues. A systematic review. Horm Mol Biol Clin Investig. 2016; 25: 71-90 PubMed Google Scholar Many physicians still avoid speaking about sex with their patients because of shame or for the general belief that sexuality and sexual dysfunctions should be considered as secondary with respect to the other severe complications of eating disorders, including medical (eg, hydroelectrolytic impairment or cardiocirculatory accidents) and psychological ones (eg, risk of comorbid depression or suicide). 1 Castellini G Lelli L Ricca V et al. Sexuality in eating disorders patients: etiological factors, sexual dysfunction and identity issues. A systematic review. Horm Mol Biol Clin Investig. 2016; 25: 71-90 PubMed Google Scholar However, empirical evidence suggests that assessing the sexual health of patients with eating disorders can be useful from different perspectives, assuming a clinical meaning beyond the concept of comorbidity. 2 Castellini G Rossi E Ricca V The relationship between eating disorder psychopathology and sexuality: etiological factors and implications for treatment. Curr Opin Psychiatry. 2020; 33: 554-561 Crossref PubMed Scopus (4) Google Scholar Indeed, the evaluation of sexual functioning might provide information regarding psychopathological features, the recovery process and the etiopathogenetic and developmental trajectory of these disorders.

Evaluation of basic nutritional parameters in older adults treated with percutaneous coronary intervention

Abstract Background Aging patients are characterized by their variability in terms of biological status and outcomes after invasive procedures. Recently, concepts of comorbidity, frailty, and nutrition have been incorporated into clinical decision-making. Of these, nutrition is the least studied component. Purpose To analyze the prevalence and impact of different baseline nutritional disorders on the clinical course in the first year after PCI. Methods We conducted a prospective observational study of consecutive patients aged ≥75 years treated by PCI in a tertiary hospital between 2014 and 2017. We evaluated the patients with baseline information on the nutritional parameters of the validated Controlling Nutritional Status (CONUT) score variables: serum albumin, total cholesterol and lymphocyte count. We analyze the prevalence of nutritional disorders, CONUT values (ranging from 0–12, with higher values indicating more severe malnutrition), and their relationship with the 12-months cumulative events rates. Results The study population comprised 209 patients (mean age 82±5 years, 40% women). The averaged laboratory values were as follows: serum albumin 3.8±0.5 g/dL, total cholesterol 141±35 mg/dL, lymphocytes 1723±913 per mL, CONUT score 2.8±2.2 points. The table shows the prevalence of each nutritional disorder, and its impact on the incidence of ischemic or hemorrhagic events. Hypoalbuminemia was significantly associated with bleeding and mortality. Notably, low cholesterol was associated with a higher incidence of vascular events in this population, and low LDLc levels did not have a protective effect. Conclusions The analysis of simple nutritional parameters is relevant in the prognostic prediction after PCI in the older adult. In particular, hypoalbuminemia and low cholesterol levels were associated with a higher incidence of adverse events. Future studies should assess the role of dietary strategies and supplements in this context. Funding Acknowledgement Type of funding sources: None. Nutrition disorders and clinical events

Hepatoprotective properties of glycyrrhizic acid

The review is devoted to the problem of treatment of non-alcoholic fatty liver disease, which is the most common pathology of the hepato-biliary system worldwide and is characterized by an increasing frequency, including of more severe forms. A wide range of pathogenetic relationships of non-alcoholic fatty liver disease with diseases of other organ systems, primarily with diseases of the cardiovascular system, type 2 diabetes mellitus, chronic kidney disease and diseases of the biliary tract, is presented. The main mechanisms of comorbidity are insulin resistance, oxidative stress, inflammation, disorders of carbohydrate and fat metabolism. An approach to the therapy of this disease based on the concept of comorbidity has been substantiated. As a rational therapeutic choice, a molecule of glycyrrhizic acid is presented, which has pleiotropic effects, including anti-inflammatory, antioxidant, antifibrotic and immunomodulatory effects. The evidence base for glycyrrhizic acid is formed by a large array of clinical trials, including randomized placebo-controlled trials conducted both in Russia and abroad, in infectious and non-infectious liver diseases, including non-alcoholic fatty liver disease. Attention is focused on non-alcoholic fatty liver disease with intrahepatic cholestasis associated with a more severe course and high rates of disease progression. A theoretical justification for the use of a combination of glycyrrhizic acid and ursodeoxycholic acid in such patients is presented. The reason for this is the potential synergy of the two molecules, based on the induction of CYP3A4, and associated with the effect on inflammation, as a factor in the development of intrahepatic cholestasis and cholestasis itself.

Medical Comorbidity in Elderly Schizophrenic Patients: A Preliminary Study in Iran

Background: While comorbidity between mental disorders and physical illnesses is the rule rather than an exception, appraising the impact of comorbidity is challenging due to lack of consensus about how to define and measure the concept of comorbidity. Objective: The aim of the present evaluation was to appraise the prevalence and features of medical comorbidities among a group of native elderly schizophrenic patients. Methods: Geriatric unit of Razi psychiatric hospital was selected as the field of investigation and 168 elderly schizophrenic patients (≥65 years old), including 101 males and 67 females, who have been hospitalized there as chronic cases, were chosen as an accessible sample, and were surveyed with respect to existing comorbid medical disorders. Psychiatric diagnosis was based on ‘Diagnostic and Statistical Manual of Mental Disorders’, 5th edition (DSM-5), and the medical diagnosis was based on ‘International Classification of Diseases’, 10th edition. Results: As shown by the results, 89% (n=151) of elderly schizophrenic patients had some kind of registered physical co-morbidity, which was more significant than the frequency of medical comorbidities among native senior citizens. Amongst the listed co-morbidities, falls, hypertension and osteoarthritis were the most prevalent comorbidities with a frequency of around 48.8%, 44.6% and 39.2%, respectively. Hypertension, renal disease and malnutrition were significantly more prevalent among male patients (p<0.0000, p<0.0045 and p< 0.0018, respectively) and hyponatremia, aspiration/ asphyxiation and seizure were meaningfully more prevalent among female patients (p<0.0075, p<0.0000 and p<0.0009, respectively). As stated by the findings and in comparison with the native seniors, while diabetes, renal diseases and malnutrition were significantly more frequent, coronary artery disease, gastrointestinal disorder and osteoarthritis were significantly less frequent in the existing sample of elderly schizophrenic patients. Conclusion: In comparison with the native senior people, the rate of medical comorbidities, particularly diabetes, renal diseases and malnutrition, was significantly higher in elderly schizophrenic patients, a significant difference, was observed regarding physical comorbidities between male and female patients, which demands further methodical and gender-based studies for defining more appropriate care.

Anesthesia in children with comorbid pathology - clinical assessment of the most common pathological conditions in the practice of anesthesiologist

Currently, there is an increase in the number of children who have multiple connected or “independent” pathological conditions, hospitalized to General hospitals with severe pain. It significantly worsens the disease course and complicates differential diagnosis in these patients, requires a deeper treatment approach. Thus, it requires attention and discussion and is urgent to cover the concept of comorbidity, combined with pain syndrome in Pediatrics. In this article is carried out the analysis of comorbid pathology in surgery from the point of view of the children’s anaesthetist. There were allocated comorbidities that are commonly encountered in daily practice and are of danger in surgical practice. We have analyzed analgesia for obesity, blood diseases, congenital heart defects, concomitant respiratory diseases – during surgery and in the postoperative period. To improve the efficiency of medical care for these patients it is important to develop an algorithm of physician's actions in the most common comorbid conditions. It is concluded that there is a need for additional studies for further clarifying the optimal management of pain and the effect of pain in case of comorbidities.

Psychotraumatisme, fonctionnement limite et addiction à l’adolescence : réévaluation de la notion de « comorbidité » pour l’hypothèse d’un « complexe » symptomatique et une nouvelle explicitation des perspectives thérapeutiques

BackgroundWe live in a world where traumatic situations seem almost permanent, shown continuously by the media. In addtion, the increase of the number of diagnoses of borderline pathologies raises the question of the location of the disorders, in particular during adolescence, according to their developmental axis and associated comorbidity. This clinical frame can lead to drug consumption and then addiction. These data being established, however, the fact is that many patients do not meet the criteria, which are sometimes too strict, of PTSD. MethodsSo, the treatment is not well adapted or clinically relevant. It does not take into account the traumatic subjectivity (real-life, emotional experience). We argue here over the concept of comorbidity and all the obstacles which can occur when providing care. These variables, to the detriment of the relationship can risk ending the development of invariable structural analysis. ResultsA comorbid symptom must be studied in reference to its time of occurrence, according to the psychopathological way where it becomes integrated, and according to its function. DiscussionWe focus on the diagnosis accuracy but also on the therapeutic strategy within a framework of an evaluative approach based on to the psychiatrist clinical creativity with the whole managing freedom.

Концепции коморбидности и мультиморбидности в ревматологии. Возможна ли смена парадигм?

Концепции коморбидности и мультиморбидности в ревматологии. Возможна ли смена парадигм?

Commentary on the Comorbidity of Alcohol Use Disorder and Depression among Patients Attending a Tertiary Hospital in the Niger Delta Region of Nigeria

A commentary on “The co-morbidity of Alcohol Use Disorder and depression among patients attending a tertiary hospital in the Niger Delta region of Nigeria” is the objective of this exercise. The study demonstrated a higher rate of alcohol use disorders (AUD) among those who presented with depressive symptoms. Furthermore, about half of the subjects who met the criteria for AUD in the study also met the criteria for depression while only a quarter of those who didn’t satisfy the criteria for AUD were also found to be depressed. This underscores the concept of comorbidity which is well documented as a challenging phenomenon for therapists. The coexistence of two chronic illnesses in the same individual constitutes double jeopardy because of their synergistic deleterious consequences on the body. Even though many plausible theories have been propounded to explain the concept of co-morbidity of AUD and Depression, none has sufficiently explained the common risk factor for and/or the exact cause of this challenge. Nevertheless, the need for a routine comprehensive clinical assessment of any patient with co-existing disorders in clinical settings is recommended.

Psychiatric comorbidities in neurodevelopmental disorders.

Recent changes in the diagnostic criteria for psychiatric and neurodevelopmental disorders as well as increases in the prevalence of both have elevated the focus on these areas of medicine and their clinical overlap. Several recent studies have examined psychiatric comorbidities in neurodevelopmental disorders including autism and specific genetic syndromes. A growing number of reports underscore the genetic overlap between previously distinct clinical disorders. Behavioral and psychiatric features are increasingly identified in association with intellectual developmental disorders. As there have been advances in our collective understanding of the genetic underpinnings of certain disorders and the downstream physiological consequences of those genetic alterations, challenges to the way boundaries have been drawn around psychiatric disorders, and by extension, the concept of comorbidity, warrant review.

Comorbidity Between Attention Deficit/Hyperactivity Disorder and Obsessive-Compulsive Disorder Across the Lifespan: A Systematic and Critical Review.

The concept of comorbidity between attention deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorder (OCD) has been discussed for two decades. No review, however, has examined this question in light of the stark contrast in disorder-specific phenomenology and neurobiology. We review reported prevalence rates and the methodological, phenomenological, and theoretical issues concerning concomitant ADHD-OCD. Reported co-occurrence rates are highly inconsistent in the literature. Studies aimed at examining the potential for comorbidity have suffered from various methodological problems, including the existence of very few community samples, highly variable exclusionary criteria, and possible clinical misinterpretation of symptoms. Despite numerous studies suggesting an ADHD-OCD comorbidity, thus far etiological (i.e., genetic) backing has been provided only for a pediatric comorbidity. Additionally, inflated rates of ADHD-OCD co-occurrence may be mediated by the presence of tic disorders, and evidence of impaired neuronal maturational processes in pediatric OCD may lead to possibly transient phenotypical expressions that resemble ADHD symptomatology. Thus, clinicians are encouraged to consider the possibility that ADHD-like symptoms resulting from OCD-specific symptomatology may be misdiagnosed as ADHD. This suggestion may account for the lower co-occurrence rates reported in adolescents and adults and for the lack of a theoretical account for comorbidity in these age groups. Existing literature is summarized and critically reviewed, and recommendations are made for future research.

Concepts of comorbidities, multiple morbidities, complications, and their clinical epidemiologic analogs

The proportion of older people in the world population is expected to increase rapidly during the upcoming decades. Consequently, the number of patients with multimorbidity will increase dramatically. In epidemiologic research, the concepts of multimorbidity, comorbidity, and complications have been confusing, and some of these concepts are used interchangeably. In this commentary, the authors propose a clear terminology for clinical concepts describing different aspects of multimorbidity and elucidate the relationship between these clinical concepts and their epidemiologic analogs. Depending on whether a study uses causal or predictive models, a proper distinction between concepts of multimorbidity is important. It can be very difficult to separate complications of the index disease under study from comorbidity. In this context, use of comorbidity indices as confounding scores should be done with caution. Other methodologic issues are type, duration, severity, and number of comorbidities included in the ascertainment methods, as well as sources included in the research. Studies that recognize these challenges have the potential to yield valid estimates of the comorbidity burden and results that can be compared with other studies.

The Conceptualization and Measurement of Comorbidity: A Review of the Interprofessional Discourse

Background. Chronic medical conditions often occur in combination. Understanding underlying mechanisms causing diseases and their interactions may make it possible to address multiple complex conditions with single or consolidated treatment approaches and improve patients' health outcomes while reducing costs. Objectives. We present a synthesis of the current interprofessional discourse on the issues surrounding comorbidities. Methods. A targeted review of the literature was conducted using published editorials, commentaries, and review articles. Results. Errors in conceptualization and measurement plague our current understanding of comorbidities. Two potential paths to generating knowledge involve the use of etiological or epidemiological approach. An etiological approach investigates the risk factors and underlying mechanisms potentially leading to consolidation of diagnosis and treatments. Because of the rudimentary stage of knowledge development in this area, this approach will require time and significant research investments. In contrast, the epidemiological approach relies on statistical identification of disease entities that cooccur beyond random chance; this approach carries an accompanying risk of diagnostic and treatment proliferation. Discussion. The concept of comorbidity, its nature, and measurement is in need of meaningful debate by the scientific and clinical communities. Recommendations in the domains of conceptualization, research, and measurement are discussed.

Autism Spectrum Disorder in DSM-V: Differential Diagnosis and Boundary Conditions

This article examines the diagnosis of autism as it has been presented in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM) and is expected to be presented in the next revision of the DSM. Then I look at the relationship of autism and other labels and conditions, including Asperger's disorder, sensory processing disorder, social communication disorder, mental retardation, social anxiety, obsessive-compulsive disorder, narcissistic disorder of childhood, and psychosis. I consider how to describe these relationships, looking at concepts of co-morbidity, overlapping borders, a range of functioning, and changes over time due to therapy, maturation, and other influences. Two vignettes illustrate these ideas.

Personality and psychopathology: the dangers of premature closure

Personality and psychopathology: the dangers of premature closure

Comorbidity indexes from administrative datasets: what is measured?

It is important to factor-in the characteristics of patients that may affect treatment, outcome and resource when making clinical and administrative decisions, plans or policies. For some two and half decades there have been efforts to construct and refine instruments that endeavour to capture the concept of comorbidity. This paper focuses on such comorbidity measures that are derived from diagnoses information recorded in administrative datasets. The pros and cons of the popular weighted Charlson and Charlson-based indexes are discussed. Means to improve the comorbidity indexes are considered including the very concept and definition of comorbidity.

Asperger’s Syndrome and Autistic Disorder: Clearly Differentiating the Diagnostic Criteria

Back to table of contents Previous article Next article Letters to the EditorFull AccessAsperger’s Syndrome and Autistic Disorder: Clearly Differentiating the Diagnostic CriteriaLEON HOFFMAN M.D.,LEON HOFFMAN M.D.Search for more papers by this author,Published Online:1 Feb 2009https://doi.org/10.1176/appi.ajp.2008.08091455AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: In their excellent, comprehensive Treatment in Psychiatry article on Asperger’s syndrome, published in the August 2008 issue of the Journal , Karen Toth, Ph.D. and Bryan H. King, M.D. (1) implicitly pointed to the inherent problems, particularly in evaluating young children, of a categorical nomenclature such as DSM. For example, the authors stated that “diagnosing Asperger’s syndrome can be tricky, as the diagnostic criteria are not clearly differentiated from those defining autistic disorder” ( 1 , p. 962). A more dimensional diagnostic approach can be found in the Psychodynamic Diagnostic Manual (2) . In the assessment of children, rather than focus on the exact categorization of any particular child, the clinician should evaluate the nature of the child’s social interactions with parents, siblings, relatives, and other children and significant adults as well as how others interact with the child. One needs to understand the nature of the child’s responses (appropriate, under-reactive, over-reactive) to sensory stimuli as well as the nature of his or her fine and gross motor development, language development, memory, fund of knowledge, and ability to understand social situations. A central clinical question is regarding whether the child’s development has proceeded smoothly or unevenly.In addition, it is necessary for the clinician to evaluate the degree to which the child’s feelings (mainly depression or anxiety) affect his or her ability to function as well as his or her sense of self, without focusing too much on the concept of comorbidity. The clinician must determine the degree to which the child’s problems are “externalizing,” “internalizing,” or a combination of both. Finally, it is important to evaluate the degree to which the child feels internal conflict in contrast to conflict with other people as well as the degree to which he or she can differentiate his or her fantasy life from real experiences.Drs. Toth and King presented such a paradigm and discussed a treatment plan whereby one can maximize the strength of the child and address the child’s developmental delays and deviations—whether they are linguistic, academic, or social—and various other symptoms. Such an approach, of course, might require an integrated interdisciplinary model.Since the capacity to relate in general can be defined on a spectrum (from no ability to relate at one end to well-related at the other), one can observe clinically many situations in which a psychodynamic approach could address the potential conflicted origins of certain social aversion, even in a child who is diagnosed with Asperger’s syndrome. Such an aversion may be the child’s defensive retreat from an anxiety-filled state when attempting social interactions.New York, N.Y.The author reports no competing interests.This letter (doi: 10.1176/appi.ajp.2008.08091455) was accepted for publication in November 2008.

Comorbidity in psychiatry: Way forward or a conundrum?

Byline: Nimesh. Desai The traditional practice of understanding and explaining all the symptoms and signs of a person presenting to mental health facilities was synchronous with the hierarchical system of classification. The clinical dictum of 'one person one diagnosis' was in keeping with the early classification systems wherein the diagnostic groups were arranged in hierarchy and clinicians were actively encouraged to arrive at one diagnosis for all the experiences and problem behaviours of each person. When a clinician came across a patient who had dependent pattern of alcohol use and significant depressive features, it was incumbent to decide the primary condition of the two. Research efforts were made to authenticate primary versus secondary alcoholism.[1] In patients with alcohol or other drug dependence and an established pattern suggestive of antisocial personality profile, it was necessary to ascertain if the substance use could be explained as part of or was epiphenomenon of the antisocial personality. The underlying approach and rationale for such practice were to simplify the diagnostic groups, and to adopt one comprehensive management strategy which would be expected to benefit all symptoms. In a person with schizophrenia and depression, it was believed that effective treatment of schizophrenia would relieve the depression and, similarly, successful therapy of the antisocial personality would control the substance use, and in secondary alcoholism, the treatment of the underlying condition would take care of the treatment of alcoholism. In 1970, Robins and Guze put forth a strong argument for making empirical evidence, through precise clinical descriptions and delineation of syndromes, the major criteria for psychiatric diagnoses.[2] About the same time, Feinstein described the term comorbidity for all chronic diseases as 'any additional clinical entity that has existed or that may occur during clinical course of a patient who has the index disease under study for chronic diseases'.[3] A well-described case in point was chronic obstructive pulmonary disease in a person with diabetes mellitus. In the 1970s, the operational diagnostic criteria based on empirical, operational and measurable attributes were popularized in psychiatry initially for research[4],[5] and later for clinical application. The introduction of the multi-axial diagnostic criteria-based classification system with the empirical, atheoretical approach contributed to a paradigm shift. Among other contributions, the one major change was the recognition of the concept of comorbidity in psychiatry by not only permitting but encouraging the clinicians to make more than one diagnoses in a person, if the criteria were adequately met for more than one disorder. At that early stage, the DSM-III stated that one diagnosis cannot be made if it is 'due to' another disorder. This provision, which was gradually made more flexible, in the subsequent classification systems, and later universalized by the ICD-10 in 1992, also following the same approach, modified not only the coding and record keeping, but more significantly broadened the perspectives of clinicians. The assessment of mental health problems of persons with multiple diagnoses, and the related implications in planning treatment and management strategies, has been significantly influenced during the 1980s and 1990s by this one paradigm shift. Soon after DSM-III, in path-breaking research, Boyd et al. in 1984, reported from a large community-based sample in USA that there was 'a general tendency toward co-occurrence, so that the presence of any disorder increased the odds of having almost any other disorder'.[6] They defined comorbidity in epidemiological terms as 'the relative risk of a person with one disorder, to receive the diagnosis of another disorder'. The current systems of DSM-IV and ICD-10 actively encourage multiple diagnoses in the same person, regardless of the possible contribution to aetiology, allowing the maximum amount of diagnostic information. …

Where do eating disorders lie on the diagnostic spectrum and what does it mean?

The aim of this paper is to review the concept of comorbidity as it pertains to eating disorders. The historical framing of eating disorders within medicine and psychiatry is described and then we move to what is understood by comorbidity in the current context of diagnostic compendiums. The issue of comorbidity highlights the unsatisfactory nature of the current description of illness phenotypes. There is a move to look for broader and more specific concepts such as that of endophenotypes, for example, in relationship to neuropsychology, and the response to reward and emotion. Finally, we consider how this approach may map onto treatment. For example, it may be necessary to have specific modules tailored to the relevant moderating and mediating factors.

Evidence in the Psychological Therapies: A Critical Guide for Practitioners

Back to table of contents Previous article Next article Book ReviewsFull AccessEvidence in the Psychological Therapies: A Critical Guide for PractitionersNorman A. Clemens, M.D.Norman A. ClemensSearch for more papers by this author, M.D.Published Online:1 Feb 2002https://doi.org/10.1176/appi.ps.53.2.216AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Psychotherapy does not fare well in the world of evidence-based medicine. It is complex and notoriously difficult to measure meaningfully. Even the goals and end points of treatment are hard to pin down. Simplistic, symptom-based outcome measures miss the essence of the treatment approach. Applying the rigors of evidence-based medicine to an enterprise that is fundamentally humanistic and based on relationships is like mixing oil and water.This slim volume tackles the challenge head-on by exhaustively addressing the nature of evidence and its application to the world of psychotherapy. The result is a thought-provoking text that strips away oversimplifications and misapplications of evidence-based medicine that threaten the field of psychotherapy.Given the serious philosophical and technical issues covered, this book is not an easy read. However, good writing and a British perspective considerably lighten the burden. The book is a well-integrated collection of essays written from various viewpoints by psychotherapy researchers and practitioners in the United Kingdom. Lucid expositions of complex issues hold the reader's attention as the story unfolds.Several aspects of the British point of view will capture the attention of U.S. readers. The politics and bureaucracy of psychotherapy under the National Health Service are glimpsed from time to time. Contributors show a healthy skepticism about DSM-IV's superficial, symptom-oriented categorization of mental illness, with its Band-Aid approach to accounting for the complexity of real-life disorders through the concept of comorbidity. These authors recognize that prevalent categorical, diagnosis-focused, narrow interpretations of evidence leave many studies of effective psychotherapy, particularly psychodynamic psychotherapy, out of consideration in evidence-based guidelines.The contributors represent both psychodynamic and cognitive-behavioral fields of practice, but U.S. readers will find it refreshing to see much less of a divide between clinical and theoretical approaches in the United Kingdom than we are accustomed to in the United States. An essay on cognitive analytical psychotherapy bridges the gap nicely. For me, as a psychoanalyst who has found the American Psychiatric Association (APA) practice guidelines disquieting in their rigid application of evidence-based medicine to favor manual-based psychotherapies supported by highly circumscribed short-term studies over valuable, widely practiced psychotherapeutic approaches, this book was a breath of fresh air.As the title suggests, Evidence in the Psychological Therapies is about evidence, not the current findings of research on psychotherapy. Early chapters stretch the reader's thinking about the nature of evidence. A fascinating explication of the historical development of concepts of evidence in jurisprudence is worth reading for its own sake.The book includes a searching critique of randomized controlled trials—now viewed as the gold standard—and an essay on the single-case method in research. A chapter on working hypotheses in psychoanalytic psychotherapy is followed by one on hypothesis testing in cognitive-behavioral therapy.The book ends with a discussion of practice-based evidence, which APA members will recognize as the Practice Research Network. The effect is to draw practitioners and researchers closer together in an effort to strengthen the true evidence base for psychotherapy.Dr. Clemens is clinical professor of psychiatry at the Case Western Reserve University School of Medicine.edited by Chris Mace, Stirling Moorey, and Bernard Roberts; Philadelphia, Brunner-Routledge, 2001, 218 pages, $64.95 hardcover, $29.95 softcover FiguresReferencesCited byDetailsCited byChildren and Youth Services Review, Vol. 26, No. 11 Volume 53Issue 2 February 2002Pages 216-216 Metrics PDF download History Published online 1 February 2002 Published in print 1 February 2002