Cochrane reviews impact on mental health policy and practice

The concept of evidence-based practice refers to the use of best available evidence when taking decisions in clinical practice. As access and use of primary evidence may be problematic for most doctors in most countries of the world, in the early 1990s the Cochrane Collaboration was established with the mission of preparing and regularly updating systematic reviews of best available evidence (Cipriani & Barbui, 2011). Nowadays over 4000 systematic reviews have been produced and are available online. In this issue of Epidemiology and Psychiatric Sciences three Editorials discuss the extent to which Cochrane reviews have been able to help doctors and policymakers make decisions, and whether the goal of implementing an evidence-based practice is getting closer (Adams, 2011; Davoli & Amato, 2011; Liberati, 2011). The authors of the three Editorials seem to agree that the Cochrane Collaboration represents a successful example of international effort aimed at providing an answer to the growing demand for valid and reliable information on the effects of health care interventions. However, all authors clearly pointed out that there is still some progress to be done, and a number of controversial issues are raised and discussed. In this presentation, we would like to emphasize one of these issues, namely the difficulties in accessing and using Cochrane reviews. Clive Adams admits that Cochrane reviews are long documents that require time and skills to be fully digested. Marina Davoli and Laura Amato describe Cochrane reviews as too lengthy with too many sections, most of which are oriented to adhere to the Cochrane standard of reporting more than to provide user-friendly information. Alessandro Liberati reports that the current format of Cochrane reviews is too burdensome even for interested researchers. This issue is not trivial, as doctors and policymakers may choose not to access and use Cochrane reviews considering the availability of less time consuming and more attractive forms of information. But these alternative forms of information, as Clive Adams warns, may bear little relationship to high-grade evidence. A paradoxical scenario seems to emerge: the Cochrane Collaboration, which was established to prepare and disseminate systematic syntheses of best available evidence as a solution to a problem of lack of easy access to primary evidence, seems to suffer exactly from the same problem. An initial solution, mentioned by the authors of the three Editorials, is the possibility of developing clinical practice recommendations based on explicit assessments of the evidence extracted from systematic reviews. This would overcome the problem of accessing systematic reviews, because doctors and policymakers would directly access and use clinical practice recommendations. One of the most well-developed approaches is the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology (Guyatt et al. 2008a, b, c). This methodology may be employed not only to develop specific treatment recommendations for professionals working in a single mental health service or department but also to develop recommendations for awide range of interventions and disorders to be adopted at a district or regional level or at a national level (Barbui et al. 2010; Barbui & Cipriani, 2011). Evidence-based recommendations may therefore be based on the results of Cochrane reviews, and may be used to establish a link between the production of evidence and its adoption in clinical practice. What is still unclear is how evidence-based recommendations should be implemented to maximize benefit at sustainable costs. This is particularly relevant not only for those involved in producing and delivering Cochrane reviews and evidence-based recommendations, including international organizations such as the Cochrane Collaboration, national institutes such as the UK National Institute for Health and Clinical Excellence * Address for correspondence: Professor Corrado Barbui, Department of Public Health and Community Medicine, Section of Psychiatry and Clinical Psychology, University of Verona, Ospedale Policlinico, Piazzale L.A. Scuro 10, 37134 Verona, Italy. (Email: corrado.barbui@univr.it) Epidemiology and Psychiatric Sciences (2011), 20, 211–214. © Cambridge University Press 2011 doi:10.1017/S2045796011000394 PRESENTATION OF THE EDITORIALS, SEPTEMBER 2011