La elección de tratamientos psicológicos basados en la evidencia. Un análisis para integrar los datos científicos con la realidad asistencial

Abstract

Nowadays there is a wide variety of psychological interventions to treat mental disorders, meaning that professionals have to weigh up which one is more effective to reach the therapeutic objectives. In this sense, during the last decades, explicit criterio have been established to determine whether a treatment is effective or not. The scientific evaluation of psychological treatments began to be systematized in the mid-twentieth century, reaching its peak during the 1980s and 1990s with the appearance of numerous randomized controlled trials (RCTs) and meta-analyzes. The proliferation of quality studies led to the emergence of a series of organizations aimed to review and disseminate those treatments supported by research and made existing institutions such as the American Psychological Association (APA) also pursue that goal. Between 1995 and 1998, a task force of the Division 12 (Society of Clinical Psychology) of the APA published several reports that identified treatments with empirical support and proposed the criteria that could be used to determine if a treatment is effective. These reports were published for Psychology students to be trained in therapies with demonstrated efficacy, and to inform practicing clinical psychologists, health insurers, and the public in general, about the existence of these treatments. Possibly, the most relevant contributions of the lists of effective treatments were establishing the explicit criteria that allow assessing the quality of the evidence of the interventions and the creation of institutions acting as mediators between research and clinical practice, serving as a reference and as a source of consultation for clinicians and academics. However, the systems used to determine the evidence for each intervention vary between institutions. In fact, they usually follow different assessment criteria, which suggests that the recommendations may differ from one organization to another. In addition, despite the endeavors made by different organizations to transfer the information provided by the research to the different actors involved, numerous studies have suggested that the knowledge held by psychologists concerning evidence-based treatments (EBTs) may be limited, suggesting that there is a need for more training, dissemination and implementation of these treatments. Some of the proposals made to improve the dissemination of these treatments among applied psychologists suggest the adaptation of the interventions to real situations of application and promoting the training of these professionals in the psychological treatment from a transdiagnostic perspective. An example of this matter may consist in developing intervention protocols composed of less than 10 sessions. This treatment modality is not sufficiently represented in the recommendations of the main organizations, but it is often applied in public and private settings in an unstructured or improvised manner. Regarding the use of a transdiagnostic treatment, its implementation would benefit clinical practice, since it may allow developing treatment modules that could be used in patients with different diagnoses or problems, which may allow avoiding that psychologists have to be trained in numerous and complex specific treatments for each disorder. Under this situation several objectives have been proposed. To accomplish them, this doctoral thesis, composed of four independent but intertwined studies, was conducted. The first study gathered the recommended EBTs for mental disorders in adults by different organizations in order to determine the level of existing agreement. To that end, the recommendations proposed by Division 12 of the APA, the National Institute for Health and Care Excellence (NICE), the Cochrane Collaboration and the Australian Psychological Society (APS) were reviewed following the PRISMA methodology for systematic reviews. A total of 135 treatments for 23 mental disorders were compiled and the degree of similarity among the recommendations proposed by each organization was analyzed. Results showed that the agreement among institutions was low for most of the disorders, observing discrepancies in the evidence presented by each one of them. These discrepancies might be due to a combination of reasons: possible biases in the procedures or in the evaluation committees, different studies reviewed by each organization to recommend a certain treatment, the use of different criteria to graduate the level of evidence, and the reviews of existing evidence were conducted in different time periods. The second study shares the aims of the previous study but focused on children and adolescents. For this, following the PRISMA methodology, the same organizations reviewed in Study 1 were analyzed, with the exception that the recommendations proposed by Division 53 (Society of Clinical Child and Adolescent Psychology) of the APA were used instead of the proposed by Division 12. A total of 137 treatments for 17 mental disorders were compiled and the degree of agreement among the recommendations proposed by each organization was examined. Results were similar to those obtained in study 1. A low agreement for most of the disorders was observed, and the same discrepancies discussed above were found. The third study aimed to determine the impact that EBTs have on the clínical practice of psychologists trained in Spain. In order to achieve this objective, a retrospective single-group ex post facto study was designed. Results confirmed that the use of EBTs by psychologists is limited, highlighting cognitive-behavioral therapies above other treatments. After analyzing some possible personal variables that could explain the use of EBTs, results indicated that the type of professional accreditation and the years of clinical experience could be related to the use of EBTs. Finally, the fourth study was directed to designing a protocol of an RCT in which the efficacy of a brief therapy adaptation of the "Unified Protocol for the transdiagnostic treatment of emotional disorders" will be examined. For this, an RCT was developed with five groups (brief therapy based on the Unified Protocol; conventional psychological treatment; conventional psychological treatment plus pharmacological therapy; mínimum intervention based on basic psychoeducational information, counseling and bibliotherapy; and usual pharmacological treatment), which would be carried out in public health centers. In this way, brief therapy will be compared with other treatment modalities frequently used in the public health system. The protocol follows the recommendations for intervention trials proposed in the SPIRIT statement -Standard Protocol Item: Recommendations for Interventional Trials-, and the rules for the communication of the trials proposed in the CONSORT statement -Consolidated Standards of Reporting Trials-. The findings of this RCT will be described in future publications, since due to the time limit for the development of this doctoral thesis, only the design of the trial and the start of its implementation were proposed as a plausible goal. In conclusion, there are significant differences among the psychological treatments recommended by the organizations included in this work due to the use of different procedures to evaluate and grade the quality of the evidence. In addition, despite the effort made by these institutions to disseminate the results of scientific research among applied professionals, it has been demonstrated that the divulgation of these findings has not been sufficiently successful among Spanish psychologists. Finally, with the aim of testing an intervention that fits the realities of healthcare public services, the protocol for a brief intervention under a transdiagnostic approach has been designed to be carried out in public health centers. In the case that the results of the study were favorable, including this type of therapies would decongest the healthcare system.