La efectividad de los tratamientos psicológicos breves y de enfoque transdiagnóstico para los trastornos emocionales en los sistemas sanitarios

Abstract

Emotional disorders (EDs), that mainly include anxiety and depressive diagnoses, are extremely prevalent worldwide. Patients with EDs do not only present affective or mental symptoms, but also have multiple limitations and difficulties in several vital areas such as work, family or social life. They present high comorbidity between them and they are the leading cause of disabilities. It is estimated that one out of six people may be suffering from an ED. Moreover, studies show how the numbers have been increasing during the last decades and they are expected to grow more in the near future. Public health systems face, therefore, the challenging task of providing efficient treatments for an exponential number of patients. However, around the half of the patients with EDs do not receive any treatment or the one they receive is not the appropriated one. This is mainly due to the fact that most of the patients with anxiety and/or depression are treated in Primary Care (PC) services, where there is not usually available any type of psychological intervention. In fact, the treatment with psychotropic drugs (mainly anxiolytics, hypnotics and antidepressants) is, by far, the most frequent for these disorders, which contradicts the recommendations of scientific research and international clinical guidelines, which point to psychological therapy as treatment of choice. Even when patients are referred to Specialized Care, the huge number of consultations and the lack of time make it impossible to follow the current manualized psychological treatment protocols. Consequently, patients with EDs do not receive the correct interventions either in this second level of attendance. All these issues in the treatment of ED carry serious consequences. In the first place, the excessive prescription of psychotropic drugs leads to addiction disorders, accidents and, in some cases, the chronification of the symptoms. Secondly, the healthcare pressure is increased when patients do not find relief for their mental problems and they consul repeatedly in PC. And last, but not least, there are exorbitant expenses due to the unreasonable prescription of medication along with the sick leaves and disabilities associated with EDs. For these reasons, new psychological therapies that might allow the effective treatment of EDs are being developed in recent years. On the one hand, the transdiagnostic approach would help to minimize the comorbidity issue, since it is design to target the underlying and shared mechanisms of all EDs. These transdiagnostic treatments would reduce the number of different interventions that clinicians need to learn and apply. Instead, only one protocol can be used for the whole set of anxiety and depressive problems. In this sense, the Unified Protocol developed by Barlow and their colleagues is one the most evidence-based transdiagnostic treatments for EDs and it has demonstrated to be as effective as other psychological specific-disorder interventions. On the other hand, brief therapies attempt to reduce the time needed to archive significant clinical changes. It appears that there is certain consensus that these therapies should have more than two and less than ten sessions. They have proven to be effective for anxiety and depressive disorders as some authors claim that they are just as effective as traditional and extensive psychological treatments. In fact, although more research is needed, they have already been successfully applied in some PC settings. By combining these two lines of action within health systems, more patients with EDs could be treated effectively in less time. In addition, other strategies are being considered as delivering psychological interventions in a group format, as part of a collaborative care or as part of a stepped care program. Despite there are some promising evidences of their effectiveness, the acceptability among patients and professionals of these last proposals seems to be questionable. Within this framework, several objectives were proposed in this doctoral thesis. To accomplish them four independent but intertwined studies were conducted. The first study was a meta-analysis that gathered the available information about brief therapies applied in PC for EDs compared with pharmacological interventions. Following PRISMA methodology, a systematic search was conducted in Medline, Embase and PsycInfo databases. We selected 33 randomized controlled trials (RCTs) that involved a total of 3868 patients. Results indicated a moderate effect size favourable to brief therapies at post-treatment (d = 0.37), but this was not maintained at follow-up. Therefore, it seems that brief therapies are, at least, equivalent to or, in some cases, superior to medication for the reduction of anxiety and depressive symptoms. Furthermore, it was not found any clinical differences between the combined treatment (brief therapies plus pharmacological intervention) and brief therapies applied by themselves, which might mean that psychotropic drugs could be unnecessary in most cases. The second study was a RCT with parallel design of three groups to compare the effectiveness of brief transdiagnostic therapy in both individual and group formats and pharmacological interventions for 102 patients with non-severe generalized anxiety disorder (GAD), mayor depressive disorder (MDD), panic disorder (PD) and/or somatoform disorder. Individual psychotherapy was developed in Specialized Care while group psychotherapy and treatment as usual was developed in PC. These psychological interventions were an adaptation of the Unified Protocol. The study followed the recommendations for intervention trials proposed in the SPIRIT (Standard Protocol Item: Recommendations for Interventional Trials) statement and the rules for the communication of the trials proposed in the CONSORT (Consolidated Standards of Reporting Trials) statement. Results showed that brief psychotherapies were more effective than medication for the reduction of EDs symptoms and diagnoses with moderate/high effect sizes. In addition, no clinical differences were found between the individual and group format. The third study aimed to determine the relation between three cognitive factors (rumination, worry, and metacognition) with the presence of GAD, PD or/and MDD symptoms from a sample of 116 individuals that consulted for the first time in PC services. Results pointed, on the one hand, that each ED had a closer link with a particular cognitive process and, on the other hand, that mixed EDs were associated with the three cognitive factors analyzed. These finding were discussed to give some recommendations to design efficient psychological treatments in terms of time and resources used. For instance, for “pure” disorders, targeting a concrete cognitive process might be the optimal therapeutic option. Nevertheless, due to the high comorbidity among EDs, the transdiagnostic treatment approach should be also considered. The fourth study was another RCT develop in PC with the objective to test one more time the effectiveness of a brief group transdiagnostic therapy for EDs compared with pharmacological interventions. Besides, two emotional regulation strategies and several cognitive factors were studied as predictors of the clinical changes. As before, this trial followed the SPIRIT and CONSORT statements. A total of 105 patients were randomized to one of the two possible interventions that were provided in PC centers. Results indicated that brief group transdiagnostic psychotherapy was more effective than medication in reducing all EDs symptoms with moderate/high effect sizes. Besides, it was found that changes in rumination, worry and metacognition could predict the improvement of MDD, GAD and PD, respectively and that these variables acted as predictors of the therapeutic change. For their part, cognitive reappraisal seemed to be linked to the improvement of a wide range of disorders, while expressive suppression could be particularly important when treating somatoform disorder. In conclusion, it seems that there is enough data to support the idea that brief and transdiagnostic psychotherapies are more effective than current interventions for the treatment of a wide range of EDs and that they could be spread within PC and Specialized Care. Although the best way of introducing these therapies is something that needs to be studied in the future, it is quite clear that they would improve people’s mental health in a more efficiently manner, since they would contribute to reduce waitlists and public costs. For that reason, governments and health managers should consider this scientific evidence and begin a health systems reform to ensure a quick and effective access to psychological therapies.