Tratamiento de la depresión en adultos con estrés adverso temprano: revisión sistemática de su efecto en síntomas relacionados a trauma, ansiedad, desajuste social y calidad de vida

Background: Early adverse stress is a risk factor for the appearance of mental health ailments during adulthood. Aim: To systematically review treatment outcomes on mental health symptoms and functional domains, and of interventions aimed at treating adults with depressive disorders and early adverse stress (EAS). Material and Methods: Systematic review and meta-analysis including experimental and quasi-experimental published studies indexed in the CINAHL, EMBASE, PubMed, and Web of Science databases, which explored the effectiveness of treatment interventions for depressive disorders in adults exposed to EAS. Data on outcomes was extracted from the included studies. A narrative, qualitative approach or a quality-effects model for meta-analysis were used for synthesizing these data. Results: Thirteen studies were included. Psychological or combined treatment interventions for depression in adults exposed to EAS may be effective in reducing trauma-related symptoms and social dysfunction in the short-and mid-term, with small effect size and without substantive heterogeneity. The assessment of anxiety symptoms and health-related quality of life yielded mixed results. Conclusions: Despite the ubiquity of EAS and its adverse and long-lasting consequences for well-being and health, treatment alternatives are scant. This review suggests that there are treatment interventions for depression in adults exposed to EAS that may achieve integral mental health benefits, alleviating its impact on various symptoms and functional domains, when EAS is explicitly considered in the treatment intervention.

Validación de la versión en español del Childhood Trauma Questionnaire-Short Form en Chile, en una muestra de pacientes con depresión clínica / Validation of the Childhood Trauma Questionnaire-Short Form in Chile

Background: Childhood Trauma Questionnaire-Short Form (CTQ-SF) is an instrument to assess child abuse and neglect Aim: to adapt and confirm the psychometric properties of the Spanish version of the CTQ-SF in Chile. Material and Methods: The CTQ-SF was applied to 89 clinically depressed subjects (77.5% women) who consulted at an outpatient mental health clinic. Confirmatory factor analysis (CFA), reliability (Cronbach's α) tests, and convergent validity analyses with clinical markers of complex depression were carried out. Results: The Chilean version of the CTQ-SF demonstrated an acceptable fit to a five-factor model, with adequate psychometric properties. The CFA revealed that a better fit to a five-factor model would be achieved after elimination of two items from the physical neglect scale, the less reliable scale of the questionnaire. The physical abuse scale discriminated between patients with a complex depression versus non-complex depression, and all the CTQ-SF's scales discriminated between patients with high suicide risk and/or history of psychiatric admissions versus those patients without this background. Conclusions: the Chilean version of the CTQ-SF shows evidence of structural and discriminant validity, and reliability, in a clinical sample. Better alternatives to specifically assess the physical neglect construct should be developed.

Tamizaje de episodio depresivo en adolescentes: validación del instrumento PHQ-9 / Screening depressive episodes in adolescents: validation of the Patient Health Questionnaire-9 (PHQ-9)

Background: There is a paucity of validated instruments for screening depression in adolescent populations in Chile. Aim: To determine the diagnostic accuracy of the adolescent version of Patient Health Questionnaire-9 (PHQ-9). Material and Methods: The PHQ-9 was transculturally adapted and administered to adolescents aged 15 to 19 years residing in Santiago de Chile, who were then evaluated with a semi structured interview (Kiddie-Schedule for Affective Disorders and Schizophrenia-Present and Lifetime Version or K-SADS-PL) and the Beck Depression Inventory. Internal validity, concurrent validity, and discriminatory power of the PHQ-9 were analyzed. Results: We evaluated 245 adolescents aged 16.2 ± 1 years (71% females). Two hundred and ten presented with a depressive episode and 35 were healthy. The sensitivity and specificity of the scale were 86.2 and 82.9% for 11 points, with a positive likelihood ratio of 5.02. Conclusions: The PHQ-9 is sensitive and specific enough to be used as a screening tool in adolescents with suspected depression. At a 11-point cut-off score as proposed, the likelihood to find a positive result in a subject with depression is five times higher.

Comorbilidad en personas con depresión que consultan en centros de la atención primaria de salud en Santiago, Chile / Comorbidity in people with depression seeking help at primary health care centers in Santiago, Chile

Background: International evidence has shown the complex interaction between depression and chronic physical diseases. Depression in scenarios involving multiple comorbidities has not received enough attention in Chile. Aim: To characterize the depressed people who consult at Primary Health Care Centers (PHCCs), taking into account the presence of chronic physical or psychiatric comorbidity. Materials and Methods: A secondary analysis of databases used in a clinical trial. Two hundred fifty six adults seeking professional help were recruited in four PHCCs located in the Metropolitan Region. These people had a major depressive episode, identified with a structured psychiatric interview (MINI), and gave their informed consent to participate. Socio-demographic information was collected, depressive symptomatology was measured with the patient health questionnaire 9 (PHQ-9), psychiatric morbidity was assessed using the Mini International Neuropsychiatric Interview (MINI), and chronic physical diseases were self-reported by the patients. Descriptive analyses of all the variables were conducted. Results: Seventy percent of patients had a history of depression, with a median of two prior depressive episodes. Depressive symptoms were mostly considered as moderate to severe and severe and 31% of the patients had high suicide risk. Seventy eight percent displayed a physical or psychiatric comorbidity. Of these patients, 29% only had a chronic physical comorbidity, while 46% suffered from an additional psychiatric disorder. Conclusions: Depressed individuals who seek help at PHCCs constitute an especially complex population that must be treated taking into account multiple comorbidities.

Barriers to access to treatment for mothers with postpartum depression in primary health care centers: a predictive model / Barreiras de acesso a tratamento para mães com depressão pós-parto em centros de atenção primária: um modelo preditivo / Barreras de acceso a tratamiento de madres con depresión posparto en centros de atención primaria: un modelo predictivo

Objective to develop a predictive model to evaluate the factors that modify the access to treatment for Postpartum Depression (PPD). Methods prospective study with mothers who participated in the monitoring of child health in primary care centers. For the initial assessment and during 3 months, it was considered: sociodemographic data, gyneco-obstetric data, data on the services provided, depressive symptoms according to the Edinburgh Postpartum Depression Scale (EPDS) and quality of life according to the Short Form-36 Health Status Questionnaire (SF-36). The diagnosis of depression was made based on MINI. Mothers diagnosed with PPD in the initial evaluation, were followed-up. Results a statistical model was constructed to determine the factors that prevented access to treatment, which consisted of: item 2 of EPDS (OR 0.43, 95%CI: 0.20-0.93) and item 5 (OR 0.48, 95%CI: 0.21-1.09), and previous history of depression treatment (OR 0.26, 95%CI: 0.61-1.06). Area under the ROC curve for the model=0.79; p-value for the Hosmer-Lemershow=0.73. Conclusion it was elaborated a simple, well standardized and accurate profile, which advises that nurses should pay attention to those mothers diagnosed with PPD, presenting low/no anhedonia (item 2 of EPDS), scarce/no panic/fear (item 5 of EPDS), and no history of depression, as it is likely that these women do not initiate treatment.

Objetivo desenvolver um modelo preditivo para avaliar os fatores que modificam o acesso a tratamento para a DPP. Métodos estudo prospectivo com mães que participaram do acompanhamento da saúde da criança em centros de atenção primária. Na avaliação inicial e durante 3 meses, foram registrados: dados sociodemográficos, gineco-obstétricos, dados sobre o uso dos serviços, sintomas depressivos de acordo com a Escala de Depressão Pós-parto de Edimburgo (EPDS) e qualidade de vida de acordo com o Questionário de Saúde SF-36. O diagnóstico de depressão foi feito com o MINI. Foram acompanhadas as mães que tinham DPP na avaliação inicial. Resultados foi construído um modelo estatístico para determinar os fatores que impediram o acesso a tratamento, constituído por: item 2 da EPDS (OR 0,43, IC95%: 0,20-0,93) e 5 (OR 0,48, IC95%: 0,21-1,09), e história prévia de tratamento para depressão (OR 0,26, IC95%: 0,61-1,06). Área sob a curva ROC para o modelo=0,79; valor de p para o teste de Hosmer-Lemershow=0,73. Conclusão foi elaborado um perfil simples, bem padronizado e preciso, que recomenda que os/as enfermeiros/as estejam atentos/as àquelas mães com DPP que apresentem anedonia baixa/nula (item 2 da EPDS), pânico/medo escasso/nulo (item 5 da EPDS) e sem antecedentes de depressão, já que é provável que estas mulheres não entrem em tratamento.

Objetivo desarrollar un modelo predictivo para evaluar los factores que modifiquen el acceso a tratamiento para la DPP. Métodos estudio prospectivo de madres que asistieron a control de niño sano en centros de atención primaria. En evaluación basal y 3 meses, se registraron: datos sociodemográficos, gineco-obstétricos, variables de uso de servicios, síntomas depresivos con la Escala de Depresión Posparto de Edimburgo (EPDS) y calidad de vida con el Cuestionario de Salud SF-36. El diagnóstico de depresión se hizo con el MINI. Se siguió a madres que en evaluación basal tenían DPP. Resultados se construyó un modelo estadístico para determinar los factores que impidieron el acceso a tratamiento, compuesto por: ítems del EPDS 2 (OR 0,43, IC95%: 0,20-0,93) y 5 (OR 0,48, IC95%: 0,21-1,09), e historia previa de tratamiento de depresión (OR 0,26, IC95%: 0,61-1,06). Área bajo la curva ROC para el modelo=0,79; valor de p para la prueba de Hosmer-Lemershow=0,73. Conclusión se elaboró un perfil simple, bien calibrado y discriminante, que sugiere que los/las enfermeros/as estén atentos/as a aquellas madres con DPP que presenten baja/nula anhedonia (ítem 2 EPDS), escaso/nulo pánico/miedo (ítem 5 EPDS), y sin antecedentes de depresión, ya que es probable que estas mujeres no ingresen a tratamiento.

Ideas autolíticas, violencia autoinfligida, y síntomas depresivos en escolares chilenos / Suicidal ideation, self-directed violence and depression among Chilean school adolescents

Background: Suicidal behaviors and depression are prevalent phenomena among adolescents, and are considered a public health problem. Aim: To determine the prevalence of depressive symptoms and suicidal behaviors and the relationship between both phenomena, in a representative sample of students from ninth grade in Santiago, Chile. Material and Methods: We recruited a probability sample of 2,597 adolescents who answered a questionnaire with questions about suicidal behavior and the Beck Depression Inventory (BDI-II). Results: The lifetime prevalence of suicidal ideation and planning was 21 and 14%, respectively. The prevalence for the past two weeks was 6.7 and 4.4% for suicidal ideation and planning, respectively. Autolytic behaviors, once in lifetime and in the past week were referred by 26 and 4% of respondents, respectively. In one third of these, self-harm coincided with recent suicide ideation or planning. All levels of suicidal behavior were more frequently reported by women. Clinically significant depressive symptoms were present in 23.5% of adolescents. Females doubled male rates. Severe depressive symptoms were present in 9.4% of the sample. A higher level of suicidal behavior correlated with more severe forms of depression. Sixty percent of adolescents who reported recent self-harm, had clinically relevant depressive symptoms. Two thirds of them had severe symptoms. Conclusions: Suicidal behavior in Chilean adolescents is prevalent, and there is an association between this behavior and the level of depression. The school is a good place to identify and develop preventive measures for teenagers.

Se puede prevenir la depresión en los adolescentes?: un estudio piloto / Can depression be prevented in adolescents?: a plilot study

Objetivo: Informar los resultados de un estudio piloto que probó la aplicabilidad, eficacia y aceptabilidad de un programa diseñado para prevenir la depresión en estudiantes secundarios. Metodología: El estudio se llevó a cabo en la comuna de San Bernardo. Se usó una metodología mixta: cualitativa y cuantitativa. Se llevó a cabo un ensayo clínico controlado con dos ramas y grupos focales. La muestra estuvo constituida por tres colegios municipales, cuatro clases de 1º Medio en el grupo activo y tres en el grupo control. La intervención de la rama activa consistió en un programa de 11 sesiones, liderado por dos profesionales jóvenes. Resultados: La muestra estuvo constituida por 277 escolares de 1º Medio, 163 en el grupo activo y 114 en el grupo control. La edad promedio de la muestra fue de 14,5 años (DE=0,6). En el diagnóstico basal, el grupo activo no se diferenció significativamente del grupo control en relación a la edad ni al nivel de sintomatología depresiva. En el grupo activo, el puntaje del BDI-II inicialmente fue de 10,7 (IC 95%=9,0 a 12,4), aumentó al término de la intervención a 11,5 (IC 95%=9,7 a 13,4) y a los 6 meses fue de 9,2 (IC 95 por ciento =7,5 a 10,9). En el grupo control, el promedio en el BDI-II fue de 9,2 (IC 95 por ciento =7,6-10,8); 8,0 (IC 95 por ciento =6,3 a 9,6) y 8,6 (IC 95 por ciento =6,1 a 11,1), respectivamente. No hubo diferencias estadísticamente significativas en los resultados entre ambos grupos en la sintomatología depresiva. Sin embargo, la intervención actuó como un factor protector para depresión (OR=0,39; IC 95%=0,19 a 0,79). En la evaluación cualitativa, los participantes calificaron positivamente el taller. Conclusiones: El estudio piloto demostró que es posible aplicar programas de este tipo en los colegios con buena aceptabilidad de los adolescentes. La resultados hasta el seguimiento a 6 meses sugieren que la intervención podría reducir la aparición de nuevos casos de depresión.

Objective: To report the results of a pilot study that tested the applicability, efficacy and acceptability of a program designed to prevent depression among secondary school students. Methodology: The study was conducted in the borough of San Bernardo. A mixed methodology was used: qualitative and quantitative. A randomized controlled trial was carried out with two arms and focus groups. The sample included three state funded schools, four 9th grade classes and three in the control group. The intervention in the active arm was an 11-session program led by two young professionals. Results: The sample constituted 277 students, 163 in the active group and 114 in the control group. The mean age of the sample was 14.5 years (SD=0.6). In the baseline diagnosis, the active group did not differ significantly from the control group regarding age and level of depressive symptoms. In the active group, the BDI-II score was initially 10.7 (95 percent CI=9.0 to 12.4) which increased at the end of the intervention to 11.5 (95 percent CI=9.7 to 13.4) and at the 6 months assessment was 9.2 (95 percent CI=7.5 to 10.9). In the control group, the BDI-II mean score was 9.2 (95 percent CI=7.6 to 10.8); 8.0 (95 percent CI=6.3 to 9.6) and 8.6 (95 percent CI=6.1 to 11.1), respectively. There were no statistically significant differences in the depressive symptoms measured between the control and active groups. However, the intervention acted as a protective factor for depression (OR=0.39; CI 95 percent =0.19 to 0.79). In the qualitative evaluation, participants appraised the program positively. They expressed greater interest in the sessions related to problem-solving strategies. Conclusions: This pilot study demonstrated that it is possible to implement programs like this in schools with good acceptance. The results reached at the time of the 6-month follow-up appear to suggest that the intervention could reduce new cases of depression.

Características de los programas de prevención en depresión en adolescentes asociados a mayor eficacia / Characteristics of prevention programs in adolescent depression associated with greater efficacy

Es de gran relevancia la investigación en prevención de depresión adolescente debido a su alta prevalencia y a las graves consecuencias asociadas. Los programas de prevención en depresión en adolescentes han sido diseñados principalmente en países desarrollados. En Chile la investigación en este tema está recién iniciándose. Las intervenciones preventivas se denominan universales cuando se aplican a toda la población, y específicas cuando se aplican a un grupo considerado de riesgo. El objetivo de este artículo es revisar las características que se han asociado a mayor eficacia de estos programas en otros países, discutiendo algunos elementos a considerar para su implementación en Chile. Los programas específicos producen tamaños de efecto mayores que los universales. Sin embargo, las intervenciones universales no deben desestimarse prematuramente, ya que tienen algunas ventajas teóricas y prácticas. Existe mayor eficacia en muestras con mayor proporción de mujeres y en adolescentes de mayor edad. Los programas implementados por profesionales de salud mental son más eficaces que los implementados por profesores, especialmente en el caso de los específicos. Se debe invertir esfuerzos en la investigación en: la necesidad de intervenir de manera diferencial de acuerdo a la edad y al género, los componentes activos que hacen que un programa sea efectivo, el costo-efectividad de estos programas, el uso de nuevas metodologías que incentiven a la participación, favorezcan la incorporación de conocimientos y la mantención de resultados.

Research in prevention of adolescent depression is highly relevant due to its high prevalence and seriously related consequences. Prevention programs in adolescent depression have been designed mainly in developed countries. In Chile, research on this topic is just beginning. Preventive interventions are called universal when they are applied to the entire population and targeted when they are applied to a group considered to be at risk. The aim of this paper is to review the features that have been associated with increased effectiveness of these programs in other countries and discussing some elements that have to be considered for their implementation in Chile. Specific programs produce larger effect sizes than universal. However, universal interventions should not be dismissed prematurely because they have some theoretical and practical advantages. There is greater efficacy in samples with higher proportion of women and older teens. The programs implemented by mental health professionals are more effective than those implemented by teachers, especially in the targeted prevention programs. It is necessary to invest research efforts in: the need to intervene differentially according to age and gender, the active components that make a program effective, cost-effectiveness of these programs, the use of new methodologies that encourage participation, promoting the incorporation of knowledge and the maintenance of long-term positive.

Yo pienso, siento, actúo: una intervención universal para la prevención de la depresión en escolares chilenos / I think, sit, act: a universal intervention for prevention of depression in chilean students

Este artículo tiene por objetivo describir la intervención realizada en colegios municipalizados, para prevenir la aparición de depresión en alumnos de 1° medio. Se trató de una intervención de tipo Universal, es decir, aplicada a todos los alumnos de la sala de clases, que constó de 12 sesiones de frecuencia semanal. La teoría Cognitiva-Conductual fue utilizada para desarrollar los contenidos de esta intervención que contó con un bloque introductorio, en el que se presentó el modelo cognitivo-conductual, las distorsiones cognitivas y estrategias para enfrentarlas (sesiones 1 a 3). Luego un bloque de detección de estilos atribucionales “depresiógenos” y estrategias para enfrentarlos (sesiones 4 a 6). El siguiente bloque fue acerca de las emociones y cómo modularlas (sesión 7). Siguió el módulo de aprendizaje de estrategias para reconocer y resolver problemas (sesiones 8 a 10), finalizando con una sesión de integración de todo lo aprendido (sesión 11) y una de convivencia y proyección del taller hacia el futuro (sesión 12). El programa fue bien recibido y aceptado por alumnos y profesores. Los problemas más significativos en su aplicación fueron los relacionados con la disciplina. Se realizaron sesiones semanales de supervisón a los facilitadotes a cargo de una psicóloga especializada en teórica cognitiva-conductual. Los resultados de esta intervención se enmarcan dentro de un ensayo clínico randomizado, que busca demostrar la efectividad en la prevención de la depresión en los escolares que asistieron al taller en comparación a un grupo control de escolares que no tuvieron el taller.

The article’s aim is to describe the Intervention made in municipal schools, to prevent the occurrence of depression in students in 9th degree. It was a Universal-type intervention that is applied to all students in the classroom, which consisted of 12 weekly sessions. Cognitive-Behavioral theory was used to develop the contents of this intervention, that had an introductory block, where was presented the cognitive-behavioral model, cognitive distortions, and it’s coping strategies (sessions 1-3). Then a unit with detection of “depressiogenic” attributional style and it’s coping strategies (sessions 4-6). The next block was about emotions and how to modulate it (session 7). Then followed, the module of learning strategies to recognize and solve problems (sessions 8-10), ending with a session to integrate what we have learned (session 11) and with a meeting with a projection of the workshop in the future (meeting 12). The program was well received and accepted by students and teachers. The most significant problems in its implementation were related to the discipline of the students in to the classroom. Sessions were weekly supervised, with the facilitators by cognitive-behavioral theory well trained senior psychologist. The results of this intervention are part of a randomized clinical trial that wants to demonstrate the effectiveness in preventing depression in students who attended the workshop compared to a control group of students who did not have the workshop.

Evaluación cualitativa desde la perspectiva de los participantes de un taller piloto diseñado para prevenir la depresión en adolescentes / Qualitative assessment from the perspective of participants of a pilot workshop designed to prevent adolescent depression

El estudio consistió en una evaluación cualitativa de la versión piloto del taller “Yo Pienso, Yo Siento, Yo Actúo”. Este taller está destinado a prevenir la depresión en adolescentes y está basado en el enfoque cognitivo-conductual. La versión piloto fue realizada el 2008 en cuatro cursos de Primero Medio, correspondientes a dos colegios de la Comuna de San Bernardo. El objetivo del estudio fue conocer las percepciones de los estudiantes que participaron en el taller piloto sobre la experiencia vivida y sus sugerencias sobre posibles modificaciones al diseño, con la finalidad de generar insumos para elaborar la versión definitiva del taller. La metodología consistió en la realización de grupos focales en cada curso intervenido, centrados en la evaluación de los componentes fundamentales del taller. Los principales resultados fueron que los participantes realizaron una evaluación general positiva del taller, que les pareció acertada la metodología de trabajo grupal y que le asignaron una gran importancia al control disciplinario en las sesiones y al vínculo que establecieron con los monitores. Los aprendizajes más significativos fueron en relación a la técnica de resolución de problemas. El espacio del taller fue valorado también como instancia de comunicación y mejoría de las relaciones interpersonales en los cursos. Las principales conclusiones fueron que el taller muestra una buena aceptación por parte de los participantes, que es importante reforzar el manejo de la disciplina durante las sesiones y que se debe garantizar la calidad del vínculo con los monitores.

The study consisted of a qualitative assessment of the pilot version of the workshop “Yo Pienso, Yo Siento, Yo Actúo” (“I think, I feel, I do”). This workshop is intended to prevent depression in adolescents and is based on the cognitive-behavioral approach. The pilot version was carried out in 2008 in four classes of Primero Medio (ninth grade) in two schools of the San Bernardo borough. The objective of the study was to understand the perceptions of students who participated in the pilot workshop on their experience and their suggestions for changes to the design with the objective of generating inputs to produce the final version of the workshop. The methodology included conducting focus groups in each class involved, focusing on the evaluation of the main components of the workshop. The main results were that participants held an overall positive assessment of the workshop; they found group work methodology successful; they attributed great importance to disciplinary control during sessions and to the relationship established with the monitors. The most significant learning was related with the technique of solving problems. The workshop environment was also related as an instance of communication and improvement of interpersonal relationships within the classes. The main findings were that the workshop showed good acceptance by the participants; it is important to strengthen the management of discipline during the sessions and to ensure the quality of the relationship with the monitors.