Are results of randomized controlled trials useful to psychotherapists?

Abstract

Two clinicians provided opposite answers to the title question: Persons argued that information from randomized controlled trials ( RCTs) is vital to clinicians, and Silberschatz argued that information from RCTs is irrelevant to clinicians.Persons argued that clinicians cannot provide top quality care to their patients without attending to findings of RCTs and that clinicians have an ethical responsibility to inform patients about, recommend, and provide treatments supported by RCTs before informing patients about, recommending, and providing treatments shown to be inferior in RCTs or not evaluated in RCTs.Silberschatz argued that RCTs do not and cannot answer questions that concern practicing clinicians.He advocates alternative research approaches ( effectiveness studies, quasi-experimental methods, case-specific research) for studying psychotherapy.The question of whether the results of randomized controlled trials ( RCTs) are useful to practicing clinicians is a controversial one in the field of the psychological therapies.We present the two sides of the argument, with Persons arguing that information from RCTs is vital to clinicians and Silberschatz arguing that information from RCTs is irrelevant.After presenting each of our points of view, each author rebuts the other's position.We conclude with a brief review of our key points of agreement and disagreement. Two Points of View Results of RCTs Are Vital to Clinicians ( Jacqueline B. Persons)Clinicians must attend to the results of RCTs for clinical, ethical, and legal reasons.I present examples of clinically useful information provided by RCTs.I also describe factors that make it difficult to export RCT-supported protocols from research to clinical settings, and I propose strategies for alleviating some of those difficulties. Importance of RCTs to CliniciansPractitioners need information from RCTs for clinical, ethical, and legal reasons.I discuss each in tum.Clinicians are routinely called upon to make decisions about alternative treatments.The RCT is designed specifically to assist in these decisions, because the RCT addresses questions of the form, Are Treatment A and Treatment B equally effective in the treatment of disorder X? Other types of studies, including naturalistic studies, can also address this question.However, a naturalistic comparison of Treatments A and B is a weaker design than the RCT because clinicians cannot be certain that the patients receiving Treatment A do not differ in some system-atic way from the patients receiving Treatment B. RCTs ( through random assignment, hence the name RCT) overcome this weak-ness ( see Chambless & Hollon, 1998).Because clinicians need information about comparative treatment efficacy and because the RCT is one of the strongest designs to answer this question, I believe that unless psychotherapists attend to RCTs, they can-not offer their patients the best quality care.Evidence from clinical trials is currently widely accepted by the scientific community as the gold standard of evidence about treatment efficacy.It is also generally accepted by the lay public; articles reporting results of clinical trials appear daily in the popular press.Because the RCT is the standard method of evalu-ating treatment efficacy, I believe that clinicians have an ethical responsibility to use RCTs to guide their work; this argument has also been made by others, including the Agency for Health Care Policy and Research, U.S. Public Health Service ([AHCPR], 1993;Klerman, 1990;McFall, 1991 ).Practicing without regard to the results of the RCTs can also have legal consequences ( Klerman, 1990).Furthermore, because RCTs are the gold standard method for comparing treatments, I believe that in this debate the burden of proof falls on clinicians who assert that RCTs are not relevant to their work. What Useful Information Do RCTs Provide to Therapists?The RCT can answer the question, All else the same, what treatment is best for disorder X? RCTs can tell us which thera-pies are superior to other active therapies, which new therapies appear equal to older therapies of known efficacy, and which therapies are superior to placebo or to no treatment.I discuss each of these points here.

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