How to integrate different sources of knowledge
Despite the success of guidelines in providing more rational and effective health care, the use of guidelines has recently been criticized as being impersonal and leaving little room for expertise of the clinician and the patients views and preferences9. Clinical expertise might enrich scientific evidence as clinicians know what actually works in practice. The experiential knowledge of patients could improve the quality of care because patients bring in the unique experience how to life with a disorder10. The combination of scientific evidence with clinical expertise and patients preferences also might stimulate the acceptability and implementation of guidelines11.
However, no coherent method has been developed thus far to integrate scientific evidence with clinical expertise and experiential knowledge. For scientific evidence the GRADE system12 has been developed, a common, sensible and transparent approach to grade quality (or certainty) of evidence and strength of recommendations. For research on clinical expertise and experiential knowledge different research methods are used (participatory research, qualitative research, narratives), but their scientific base is not as strong as in evidence based medicine. Furthermore, a procedure how to weigh each domain of knowledge is currently lacking.
The developmental process of the standard of care for depressive disorders showed how clinical expertise and experiential knowledge supplemented scientific evidence in cases where evidence was weak or lacking. Interesting here is the adoption of art therapies in this standard of care although the evidence for the efficacy of art therapies is currently lacking. Psycho-analytic psychotherapy is added as an optional psychotherapeutic method, despite a weak scientific base, because of the strong appreciation of professionals for this form of psychotherapy, at least in our country. Methods to assemble experiential knowledge were a survey among members of the consumers organization and a focus group meeting. Consensus meetings in the working committee were used to weight the recommendations that came from the different perspectives and that method proved effective but is of course not fully transparent. It is important to develop an general accepted procedure to integrate scientific evidence, clinical expertise and experiential knowledge in practice guidelines.