19. 11. 2009
Hand in hand with an inflation of treatment guidelines across Europe, the gap between recommendations based on evidence and clinical practice paradoxically increases. There are several reasons for which guidelines use to be disregarded in everyday practice. First, there are always stakeholders staying out of consensus and therefore reluctant to support the implementation of its outcome. Second, most of guidelines are predominantly focused on pharmacotherapy to the detriment of other treatment modalities. Third, in contrast to the practical life guidelines often lack the recommendations for physical health monitoring and treatment as well as the management of co-morbidities, drug abuse etc.. Clinical experience, on the other hand, can answer questions (and has to solve problems), which are not covered by evidence, e.g., individual responsiveness to a drug and to other treatment modalities, individual sensitivity to side effects, individual psycho-social situation, individual defence and copying mechanisms etc. Too extensive and rigid application of guidelines can decrease the clinical motivation of doctors, can slow down the process of therapeutic innovations and can even lead to malpractice. Psychiatry as a medical discipline is now challenged in terms of the classification (categorical vs dimensional), in terms of diagnostic validity, and in terms of optimizing the proportion of “science” and “art” in the world where professional decision making process is more and more driven by payers, by reimbursement policies, and by business administration.