心身医療におけるEBM : 心身医学と医療統計学をつなぐアプローチ(心身医療におけるエビデンス・ベイスト・アプローチとナラティブ・アプローチ:理論・実践・研究,シンポジウム,第47回日本心身医学会総会)  [in Japanese] Evidence Based Medicine in the Filed of Psychosomatic Medicine : Approach for the Connection between Psychosomatic Medicine and Biostatics(Symposium/Evidence-based Approach and Narrative Approach in Psychosomatic Medicine: Theory, Practice and Research)  [in Japanese]

Evidence based medicine (EBM)とは,「現時点で利用可能な最善の科学的根拠を駆使しながら,患者側の価値観・期待,医療者側の専門技能の双方に配慮した」うえでの根拠に基づく医療を実践することである.心療内科ではいつもさまぎまな患者と接しているが,その病態はさまざまで,十分な情報が得られないこともある.そうした場合でも医師として与えられた条件の中で現時点における問題点と緊急性を判断し,必要な検査・治療を進めながら経過を追うか,さらに専門の医師にコンサルトするといった具体的な措置を講じなくてはならない.その判断は,あやふやな経験や直感に頼ってはだめで,「最新で最善の根拠を良心的かつ明確に,思慮深く利用する」ことが大切となる.本稿では,EBMを活用するための基本的な方法について解説した後,「高血圧症へのリラクセーション療法」を1例として心身医学におけるEBMについて考えてみた.

Evidence-based medicine (EBM) is the integration of best external evidence with clinical expertise and patient values. The full-blown practice of EBM comprises the following 5 steps; converting the need for information (e.g. diagnosis, prognosis, therapy, and prevention) into an answerable question (step 1), tracking down the best evidence with which to answer that question (step 2), critically appraising that evidence for its validity, impact, and applicability (step 3), integrating the critical appraisal with our clinical expertise and with the patient's unique biology, values and circumstances (step 4), and evaluating our effectiveness and efficiency in executing steps 1 to 4 and seeking ways to improve them both for next time (step 5). Concerning the step 1, it is often difficult to define "exposure" and "outcome" clearly in the field of psychosomatic medicine. For my clinical and research experience under Herbert Benson, M.D at Mind/Body Medicine, Harvard Medical School (1998-2001), definitions of stress and relaxation were quite elaborate tasks to assess the effects of stress management program in the treatment of patients with mind/body distress (Nakao M, Fricchione G, Benson H, et al. Psychother Psychosom 70: 50-57, 2001). He used the word of "relaxation response" instead of "relaxation", and defined it as follows; "the relaxation response is the psychological and physiological opposite of the arousal or stress response, characterized by decreased metabolism, blood pressure, rate of breathing and heart rate in association with feelings of calmness and control." Although general interest in relaxation therapies is on the rise, research in this area does not seem to be growing at the same pace. The working group of the Cochrane library has just begun their work to accumulate literature concerning relaxation therapies for the management of essential hypertension in adults (Nicolson DJ, et al. The Cochrane Database of Systematic Reviews, Volume 1, 2006 [Protocol]). According to this recent report, relaxation therapies include autogenic training, cognitive therapy, behavioral therapy, meditation, guided imagery, biofeedback, progressive muscle relaxation, breathing exercises, and yoga. They identified five systematic reviews, one of which was published by us (Nakao M, Yano E, Nomura S, et al. Hypertens Res 26: 37-46, 2003). In our systematic review, 388 articles were initially selected for review of biofeedback treatment for essential hypertension, but only 22 articles met inclusion criteria for further review and meta-analysis, meaning that the remaining 366 articles did not have enough information based on the standardized quality assessment. Although psychosomatic medicine is comprised of different approaches including internal medicine, psychiatry, psychology, sociology, and behavioral medicine, it should be recognized and applied in the mainstream of medicine, and many researchers and practitioners are needed to be involved in establishing the EBM of psychosomatic medicine.