Treatment Practice Guidelines Research Articles

Evidence-based social work practice: Challenges and promise

Following an outline of basic premises that lend meaning to and support evidence-based practice (EBP), this article discusses three obstacles that challenge implementation of EBP in routine practice: (1) the uncritical transfer and use of lay decision heuristics, (2) espousal of epistemologies that are inhospitable to EBP, and (3) the dilemma that is inherent in idiographic application of empirical generalizations. The author presents a conception of practice guidelines for intervention (PGI), in which principles and procedures drawn from single-system design and systematic planned practice are integrated. The PGI culminates with an outline of an algorithm for implementation of empirically supported interventions that reconciles its uncertain fit to an individual client through a recursive adaptation--application--evaluation process to maximize outcome attainment. Implications for research and for professional education are drawn. Key words: evidence-based practice; practice guidelines; implementation; interventions ********** Evidence-based practice (EBP) has been advocated in a number of human services professions, first in medicine (Evidence-Based Medicine Working Group, 1992), and more recently in psychiatry, clinical psychology, and social work (Addis, 2002; Drake et al., 2001; Gambrill, 1999; Gibbs & Gambrill; 2002). It has come to signify reaffirmation of a profession's commitment to a scientific knowledge base in general, and more specifically, an expectation that practice decisions be based on evidence from scientific research. The emphasis on EBP was fueled, to a large extent, by a growing realization that practitioners do not routinely use the best available evidence for their practice decisions. But even in medicine, where scientific tradition and reliance on the products of research are much more firmly rooted than in social work, the advocated transition to evidence-based medicine is not without its challenges and entails profession-wide readjustments (Tanenbaum, 1999). Advocacy for EBP has had few tangible results in social work. Despite the growing recognition of EBP's appropriateness, I am not aware of a practice effort in which EBP was systematically implemented and evaluated. Also, findings from studies of practitioners' use of research in practice have been disappointing (Rosen, 1994; Rosen, Proctor, Morrow-Howell, & Staudt, 1995). I believe that factors inherent in practitioners and in the practice situation render much of EBP incompatible with its routine application in practice. Such incompatibility has rarely been recognized or addressed constructively (Rosen, 1983, 1996). Instead, researchers have tended to place the burden of utilization on practitioners (Wakefield & Kirk, 1996), thus contributing to further and unnecessary alienation between researchers and practitioners (Kagle & Cowger, 1984; Karger, 1983). If EBP is to be implemented more generally, practitioners must be provided with tools to facilitate such implementation. To that end, after highlighting basic premises of social work that undergird EBP, I describe some of the obstacles to implementation of EBP and suggest procedures to attenuate their undesired influence and enhance implementation. Although the discussion to follow is primarily in the language of clinical practice, it is also relevant to social work practice in other contexts. BASIC PREMISES OF PROFESSIONAL SOCIAL WORK PRACTICE Commitment to the Client's Best Interest Commitment to client's best welfare is the most basic premise of professional practice. It mandates that practitioners relentlessly pursue the client's best interests. To abide by this premise practitioners must be sensitive to cultural and individual diversity and distinguish the client's welfare from their own interests and from their culturally moderated conception of what is in the client's best interest. …

Clinical pharmacology of anti-Alzheimer drugs.

Alzheimer's disease (AD) is a chronic neurodegenerative disorder characterized by a progressive loss of cognitive and functional abilities, associated with various degrees of behavioural disturbances, with a devastating impact on public health and on the whole society. Slowing of cognitive impairment, duration of disease, self-sufficiency and behavioural disturbances represent the best outcomes of the pharmacologic therapy. Cholinesterase inhibitors (ChE-I) have been shown to be effective in the treatment of the cognitive, behavioural, and functional deficits of AD. In addition to ChE-I, a number of studies have been carried out to investigate the possible use of other compounds and pharmacologic strategies; more compounds, postsynaptic muscarinic and nicotinic receptor agonists, are under investigation. The standard suggested care for pharmacologic management of the cognitive and functional disabilities of AD at present consists of treatment with ChE-I. Practice recommendations and treatment guidelines are derived from clinical trials.

Practice guidelines for Parkinson's disease

‘Practice Guidelines (PG) or treatment guidelines’ are not infallible guidelines but tools with which to support a clinical decision, i.e. one factor when making a clinical decision. When making a clinical decision, medical practice is determined by taking into consideration PG, a patient's preferences, and a country's social and healthcare systems. Even if a PG provides a treatment method based on a high-level of evidence, the method simply represents a mean result obtained from past clinical studies, which are not always uniformly applicable to all patients. When consulting a PG, it is advisable to know in advance what group/society/organization prepared it, the purpose of its preparation, and the developmental method, including social equity, whether healthcare costs are assumed in the PG or whether the pharmaceutical industry had substantial involvement in its development. Thus, PGs need to be developed according to the actual conditions in a country or institution. As to the questions whose answers are not provided in a PG, these issues have to be defined and assessed through a literature search. This is the so-called implementation of Evidence-Based Medicine (EBM). The concepts of EBM further require the provision of better evidence. A PG is always fated to be out of date by the time it is published because new evidence is continually being published. It is therefore, always necessary to search for the most up to date evidence available.