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Welcome to the nexus of ethics, psychology, morality, technology, health care, and philosophy
Showing posts with label Clinical Guidelines. Show all posts
Showing posts with label Clinical Guidelines. Show all posts

Friday, September 8, 2017

Errors in the 2017 APA Clinical Practice Guideline for the Treatment of PTSD: What the Data Actually Says

Dominguez, S. and Lee, C.
Front. Psychol., 22 August 2017

Abstract

The American Psychological Association (APA) Practice Guidelines for the Treatment of Posttraumatic Stress Disorder (PTSD) concluded that there was strong evidence for cognitive behavioral therapy (CBT), cognitive processing therapy (CPT), cognitive therapy (CT), and exposure therapy yet weak evidence for eye movement desensitization and reprocessing (EMDR). This is despite the findings from an associated systematic review which concluded that EMDR leads to loss of PTSD diagnosis and symptom reduction. Depression symptoms were also found to improve more with EMDR than control conditions. In that review, EMDR was marked down on strength of evidence (SOE) for symptom reduction for PTSD. However, there were several problems with the conclusions of that review. Firstly, in assessing the evidence in one of the studies, the reviewers chose an incorrect measure that skewed the data. We recalculated a meta-analysis with a more appropriate measure and found the SOE improved. The resulting effect size for EMDR on PTSD symptom reduction compared to a control condition was large for studies that meet the APA inclusion criteria (SMD = 1.28) and the heterogeneity was low (I2 = 43%). Secondly, even if the original measure was chosen, we highlight inconsistencies with the way SOE was assessed for EMDR, CT, and CPT. Thirdly, we highlight two papers that were omitted from the analysis. One of these was omitted without any apparent reason. It found EMDR superior to a placebo control. The other study was published in 2015 and should have been part of APA guidelines since they were published in 2017. The inclusion of either study would have resulted in an improvement in SOE. Including both studies results in standard mean difference and confidence intervals that were better for EMDR than for CPT or CT. Therefore, the SOE should have been rated as moderate and EMDR assessed as at least equivalent to these CBT approaches in the APA guidelines. This would bring the APA guidelines in line with other recent practice guidelines from other countries. Less critical but also important, were several inaccuracies in assessing the risk of bias and the failure to consider studies supporting strong gains of EMDR at follow-up.

The article is here.

Friday, June 19, 2015

Emerging Ethical Threats to Client Privacy in Cloud Communication and Data Storage.

By Samuel D. Lustgarten
Professional Psychology: Research and Practice, Apr 27 , 2015. http://dx.doi.org/10.1037/pro0000018

Abstract

In June 2013, Edward Snowden released top-secret intelligence documents that detailed a domestic U.S. spying apparatus. This article reviews and contends that current APA ethics and record-keeping guidelines, the Health Insurance Portability and Accountability Act, and the Health Information Technology for Economic and Clinical Health Act do not adequately account for this new information and other emerging threats to client confidentiality. As psychologists bear the responsibility for being informed, protecting and maintaining client records, and preventing breaches, it is vital that the field establish specific best practices and present regular security updates to colleagues.

Here is an excerpt:

Unfortunately, on top of data-mining practices, most cloud storage and communication providers do not provide adequate information about data-retention policies. Google's Drive cloud storage service for personal users (not Google Apps) offers no specific data-retention policy (Google, 2014c). This amorphous data-retention policy stands in contrast to APA's (2007) record-keeping guidelines, which suggest that client records and data may be destroyed after 7 years in the absence of superseding legal requirements. It also calls into question a practitioner's ability to maintain and provide confidentiality and proper informed consent when using certain corporate providers. Moreover, it is questionable whether practitioners could ever believe that records had been deleted if the cloud provider did not clearly and publicly state its data-retention standards.

The entire article is here.

Thursday, May 7, 2015

10 years of mindlines: a systematic review and commentary

By Sietse Wieringa and Trisha Greenhalgh
Implementation Science 2015, 10:45
doi:10.1186/s13012-015-0229-x
Published: 9 April 2015

Abstract

Background

In 2004, Gabbay and le May showed that clinicians generally base their decisions on mindlines—internalised and collectively reinforced tacit guidelines—rather than consulting written clinical guidelines. We considered how the concept of mindlines has been taken forward since.

Methods

We searched databases from 2004 to 2014 for the term ‘mindline(s)’ and tracked all sources citing Gabbay and le May’s 2004 article. We read and re-read papers to gain familiarity and developed an interpretive analysis and taxonomy by drawing on the principles of meta-narrative systematic review.

Results

In our synthesis of 340 papers, distinguished between authors who used mindlines purely in name (‘nominal’ view) sometimes dismissing them as a harmful phenomenon, and authors who appeared to have understood the term’s philosophical foundations. The latter took an ‘in-practice’ view (studying how mindlines emerge and spread in real-world settings), a ‘theoretical and philosophical’ view (extending theory) or a ‘solution focused’ view (exploring how to promote and support mindline development). We found that it is not just clinicians who develop mindlines: so do patients, in face-to-face and (potentially) online communities.

Theoretical publications on mindlines have continued to challenge the rationalist assumptions of evidence-based medicine (EBM). Conventional EBM assumes a single, knowable reality and seeks to strip away context to generate universal predictive rules. In contrast, mindlines are predicated on a more fluid, embodied and intersubjective view of knowledge; they accommodate context and acknowledge multiple realities. When considering how knowledge spreads, the concept of mindlines requires us to go beyond the constraining notions of ‘dissemination’ and ‘translation’ to study tacit knowledge and the interactive human processes by which such knowledge is created, enacted and shared. Solution-focused publications described mindline-promoting initiatives such as relationship-building, collaborative learning and thought leadership.

Conclusions

The concept of mindlines challenges the naïve rationalist view of knowledge implicit in some EBM publications, but the term appears to have been misunderstood (and prematurely dismissed) by some authors. By further studying mindlines empirically and theoretically, there is potential to expand EBM’s conceptual toolkit to produce richer forms of ‘evidence-based’ knowledge. We outline a suggested research agenda for achieving this goal.

The entire article is here.