ABSTRACT
Una parte sustancial de las consultas de Atención Primaria (AP) tiene como motivo principal algún tipo de trastorno emocional, especialmente los relacionados con la depresión, la ansiedad y las somatizaciones. Estos trastornos mentales más comunes tienen altos costes para los afectados y para la sociedad en general. Pese a la existencia de terapias psicológicas que han demostrado ser eficaces para esos trastornos, rara vez se utilizan en el primer nivel asistencial. El objetivo del proyecto de Psicología en Atención Primaria (PsicAP) es demostrar la eficacia de una terapia de cognitivo-conductual grupal transdiagnóstica para tratar los trastornos emocionales más frecuentes en AP. Esta terapia, de sólo 7 sesiones, es especialmente apropiada para el contexto de AP. En este trabajo se presenta el manual de tratamiento, sesión a sesión, con extractos que ilustran contenidos clave de las sesiones. Finalmente, se discuten las implicaciones de un protocolo de estas características en un momento en el que el psicólogo clínico y el residente de Psicología Clínica empiezan a estar presentes en AP en España
A substantial percentage of primary care (PC) visits are motivated by some type of emotional disorder, especially depression, anxiety and somatization. These common mental disorders represent a significant burden for the people affected and for the society. Despite the availability of effective psychological therapies for these disorders, psychological interventions are rarely used in PC. The aim of the Psychology in Primary Care (PsicAP) project is to demonstrate the efficacy of a transdiagnostic cognitive-behavioural group therapy to treat the most prevalent emotional disorders in PC. This therapy, which involves only 7 sessions, is especially appropriate for PC settings. In the present article, we present the treatment manual, session by session, with extracts that illustrate key contents of the sessions. Finally, we discuss the implications of a protocol of this type at a time when clinical psychologists and clinical psychology interns are starting to be integrated into the PC setting in Spain
Subject(s)
Humans , Affective Symptoms/psychology , Primary Health Care , Mental Disorders/psychology , Psychotherapy/methods , Psychophysiologic Disorders/psychology , Depression/psychology , Anxiety Disorders/psychologyABSTRACT
Los trastornos mentales comunes son los más prevalentes en atención primaria (AP) en España. Desgraciadamente existe un porcentaje elevado de casos que no son detectados correctamente, tanto por infradiagnóstico como por sobrediagnóstico. Una incorrecta detección de estos trastornos conlleva que los pacientes no sean derivados correctamente, así como que un 39% no reciba ningún tratamiento y solo uno de cada 3 pacientes tratados siga un tratamiento mínimamente basado en la evidencia. En el ensayo clínico PsicAP se han estudiado las propiedades psicométricas del Patient Health Questionnaire (PHQ) y sus diferentes módulos, de ansiedad (GAD-7), depresión (PHQ-9) y pánico (PHQ-PD), así como una prueba ultra-corta derivada del PHQ (PHQ-4), para ansiedad y depresión. En este trabajo se hace una propuesta razonada acerca de un modelo jerárquico de diagnóstico y derivación de los trastornos mentales comunes, basado en estos instrumentos validados para la población española que acude a AP
Common mental disorders are the most prevalent in primary care (PC) centres in Spain. Unfortunately, there is a high percentage of undetected cases, due to underdiagnosis or overdiagnosis. An incorrect identification of these disorders leads to inaccurate referrals; 39% receive no treatment and only one in three patients treated follow a minimally evidence-based treatment. In the PsicAP clinical trial, the psychometric properties of the Patient Health Questionnaire (PHQ), its different modules of anxiety (GAD-7), depression (PHQ-9) and panic disorder (PHQ-PD), and an ultra-brief version derived from the PHQ for anxiety and depression (PHQ-4) have been analysed. A diagnostic and referral hierarchical model of common mental disorders is proposed based on the validation of these instruments among patients attending Spanish PC centres
Subject(s)
Humans , Triage/methods , Mental Disorders/epidemiology , Referral and Consultation/statistics & numerical data , Primary Health Care/statistics & numerical data , Models, Organizational , Psychometrics/instrumentation , Mass Screening/methodsABSTRACT
BACKGROUND: Demand for primary care (PC) services in Spain exceeds available resources. Part of this strong demand is due to the high prevalence of emotional disorders (EDs)-anxiety, depression, and somatic symptom disorders-and related comorbidities such as pain or chronic illnesses. EDs are often under- or misdiagnosed by general practitioners (GPs) and, consequently, treatment is frequently inadequate. OBJECTIVE: We aim to compare the short- and long-term effectiveness of group-delivered transdiagnostic cognitive behavioral therapy (TD-CBT) versus treatment as usual (TAU) in the treatment of EDs in the PC setting in Spain. We also aim to compare the effect of these treatments on disability, quality of life, cognitive-emotional factors, and treatment satisfaction. METHODS: Here we present the study design of a two-arm, single-blind, randomized controlled trial (N=1126) to compare TAU to TD-CBT for EDs. TAU will consist primarily of pharmacological treatment and practical advice from the GP while TD-CBT will be administered in seven 90-minute group sessions held over a period ranging from 12 to 14 weeks. Psychological assessments are carried out at baseline (ie, pretreatment); posttreatment; and at 3-, 6-, and 12-month follow-up. The study is conducted in approximately 26 PC centers from the National Health System in Spain. RESULTS: This study was initiated in December 2013 and will remain open to new participants until recruitment and follow-up has been completed. We expect all posttreatment evaluations to be completed by December 2017, and follow-up will end in December 2018. CONCLUSIONS: We expect the TD-CBT group to have better results compared to TAU on all posttreatment measures and that this improvement will be maintained during follow-up. This project could serve as a model for use in other areas or services of the National Health System in Spain and even in other countries. CLINICALTRIAL: International Standard Randomized Controlled Trial Number (ISRCTN): 58437086; http://www.isrctn.com/ISRCTN58437086 (Archived by WebCite at http://www.webcitation.org/6mbYjQSn3).
ABSTRACT
INTRODUCTION: Panic disorder is a common anxiety disorder and is highly prevalent in Spanish primary care centres. The use of validated tools can improve the detection of panic disorder in primary care populations, thus enabling referral for specialized treatment. The aim of this study is to determine the accuracy of the Patient Health Questionnaire-Panic Disorder (PHQ-PD) as a screening and diagnostic tool for panic disorder in Spanish primary care centres. METHOD: We compared the psychometric properties of the PHQ-PD to the reference standard, the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) interview. General practitioners referred 178 patients who completed the entire PHQ test, including the PHQ-PD, to undergo the SCID-I. The sensitivity, specificity, positive and negative predictive values and positive and negative likelihood ratios of the PHQ-PD were assessed. RESULTS: The operating characteristics of the PHQ-PD are moderate. The best cut-off score was 5 (sensitivity .77, specificity .72). Modifications to the questionnaire's algorithms improved test characteristics (sensitivity .77, specificity .72) compared to the original algorithm. The screening question alone yielded the highest sensitivity score (.83). CONCLUSION: Although the modified algorithm of the PHQ-PD only yielded moderate results as a diagnostic test for panic disorder, it was better than the original. Using only the first question of the PHQ-PD showed the best psychometric properties (sensitivity). Based on these findings, we suggest the use of the screening questions for screening purposes and the modified algorithm for diagnostic purposes.
Subject(s)
Mass Screening/methods , Panic Disorder/diagnosis , Primary Health Care , Surveys and Questionnaires , Adolescent , Adult , Aged , Female , Humans , Male , Middle Aged , Spain , Young AdultABSTRACT
Se presenta un caso de intervención psicológica llevado a cabo con una mujer de 36 años, que acude a consulta diagnosticada de vaginismo tras haber recibido tratamiento psicológico basado en exposición sin resultados satisfactorios. En la primera entrevista se le diagnostica un trastorno por estrés postraumático (TEP) por violación encontrándose síntomas de reexperimentación muy intensos, con pesadillas y flashbacks frecuentes, destacada hipervigilancia, evitación de casi todas las actividades cotidianas (trabajar, salir de casa, etc) así como niveles de activación fisiológica muy elevados, Presenta también un trastorno depresivo mayor (TDM). El tratamiento mediante reestructuración cognitiva que se ha utilizado resalta el papel de la autorregulación emocional en los trastornos emocionales (Moses y Barlow, 2006) y recoge una síntesis de los principales modelos y técnicas de reestructuración cognitiva: (1) explicación de los cambios y las secuelas que se producen a nivel cognitivo, fisiológico y motor tras haber sido víctima de una experiencia traumática, destacando el papel del aprendizaje emocional en el desarrollo del problema: (2) entrenamiento en observación de pensamientos, imágenes, respuestas fisiológicas y conductas, relacionados con el aprendizaje emocional traumático, tratando de interpretarlos como una reacción adaptativa; (3) reinterpretación correcta de las reacciones cognitivas, emocionales y conductuales que se van desarrollando en su vida cotidiana, dotando así a la paciente de estrategias cognitivas de manejo de esas reacciones; (4) reforzamiento de las iniciativas propias a la hora de volver a exponerse a situaciones emocionales, y (5) persuasión sobre la eficacia del tratamiento. Tras 32 sesiones ( las 28 primeras con periodicidad semanal), se consiguieron los objetivos terapéuticos, destacando eliminación del TEP, el TDM y el vaginismo (AU)
This manuscript presents a case of psychological intervention for a 36 year old woman who seeks treatment after receiving exposure-based psychological treatment for a diagnosed vaginismus without satisfactory results. During the first interview, she is diagnosed with post traumatic stress disorder (PTSD) following sexual assault given the intense reexperienceing symptoms, including nightmares an flash backs continual and increased vigilance, avoidance of every-day activities (work, leave the house, etc) and hyperarousal. She also suffers form major depressive disorder (MDD). The cognitive restructuring treatment employed highlights the role of emotional self-regulation in emotional disorders (Moses & Barlow, 2006) and synthesizes the principal cognitive restructuring models and techniques: (1) explaining the changes and sequelae that arise at a cognitive, physiological and behavioural level after experiencing a traumatic experience, emphasizing the role of emotional learning in the development of the problem; (2) self-monitoring training of thoughts, images, physiological and behavioural responses, associated with traumatic emotional learning, with the aim of interpreting the information in an adaptive way; (3) correctly reinterpreting everyday life cognitive, emotional and behavioural reactions, helping the patient to handle such reactions by using cognitive strategies; (4) reinforcing the patient´s initiative to confront emotional situations; and 85) persuading of the efficacy of the treatment. After 32 sessions (the first 28 on a weekly basis), the therapeutic objective were achieved, having eradicated PTSD, MDD and vaginismus (AU)
