Governing Sadness: An Institutional Ethnography of Evidence-Based Medicine and the NICE Guideline on Depression in Adults

Abstract

Evidence-Based Medicine (EBM) began as an approach to interpreting clinical evidence and ensuring it was applied in everyday clinical practice. 30 years later, the imperative to be evidence-based has extended far beyond these original goals, reshaping almost all areas of medical practice and public service delivery. Despite its impact and widespread critique, analyses of EBM are still largely limited to its methodological or clinical components, which do little to account for its persistence. My thesis aims to broaden thinking on EBM, offering a contemporary account of EBM through the lens of Evidence-Based Psychiatry (EBPsych).

I take a feminist and survivor-rooted approach to think through EBM and EBPsych, using Institutional Ethnography as a mode of enquiry. Specifically, my work explores the National Institute of Health and Care Excellence (NICE)’s controversial evidence-based guideline on Depression in Adults. In doing so, I pay attention to the impact of EBM on what gets to count as legitimate medical knowledge, the role of expertise in medicine, and the entanglement of politics and science. To offer a wider analysis of EBM, I developed a three-step analytical framework zooming from the granular to the abstract; beginning with institutional texts themselves and working out to the ideological and discursive.

To conclude, I show how EBM is used to contain and govern issues relating to psychiatry and knowledge controversies more broadly. EBM serves not only as a way of dealing with medicine, but also a way of doing medicine that (re)articulates and (re)positions medical knowledge, expertise, and patienthood. My hopes for the thesis are twofold; firstly to generate more nuanced readings of EBM, and secondly to support survivor-led efforts to (re)imagine responses to distress.