Guía de Práctica Clínica - No GES
Para el abordaje de Depresión en Adolescentes
ETD5
En adolescentes con diagnóstico de depresión, el Ministerio de Salud SUGIERE realizar intervención psicológica con frecuencia 1 vez a la semana por sobre 1 vez al mes.
Comentarios del Panel de Expertos:
►Pudiera ser favorable una mayor frecuencia de sesiones al inicio de la terapia, y luego ir distanciándolas a medida que el adolescente presente una evolución clínica favorable.
El panel de expertos analizó y debatió cada uno de las preguntas de la “Tabla de la evidencia a la decisión”, considerando tanto la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de los pacientes. Una vez consensuada la postura del panel respecto a las preguntas, emitieron un juicio seleccionando la opción de respuesta que mejor representaba la opinión del conjunto (destacada con color). Finalmente, cuando el panel emitió su juicio sobre todas las preguntas, se emitió la recomendación.
A continuación, se presenta la “Tabla de la evidencia a la decisión” con el resumen de los juicios, la evidencia de investigación evaluada, consideraciones adicionales y comentarios planteados por el panel.
1.- ¿El problema es una prioridad?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
El problema ha sido definido como prioritario en el marco de las Garantías Explícitas en Salud (GES), régimen integral de salud que prioriza un grupo de patologías o problemas de salud, garantizando el acceso a tratamiento oportuno y de calidad.
2.- ¿Qué tan significativos son los efectos deseables anticipados?
| Triviales | Pequeños | Moderados | Grandes | Varía | No lo sé |
|---|
Grandes: El panel de expertos de la Guía estimó que los efectos deseables de «realizar intervención psicológica con frecuencia 1 vez a la semana» en comparación a «realizar intervención psicológica con frecuencia 1 vez al mes» son grandes, considerando la evidencia, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud. El panel agrega que desde su experiencia clínica el aumentar la frecuencia de sesiones posiblemente disminuye de sintomatología, previenen el riesgo suicida y mejora la funcionalidad psicosocial.
Evidencia de investigación
FRECUENCIA 1 VEZ A LA SEMANA COMPARADO CON 1 VEZ AL MES PARA DEPRESIÓN EN MENORES DE 15 AÑOS.
Pacientes Personas menores de 15 años con diagnóstico de depresión.
Intervención Intervención psicológica con frecuencia 1 vez a la semana.
Comparación Intervención psicológica con 1 vez al mes.
|
Desenlaces |
Efecto* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
|
|
Efectividad |
Una revisión sistemática concluyó, mediante regresión logística, que había un aumento de la efectividad según frecuencia de sesiones. (Pendiente del efecto de 0,40 IC 95% 0,12 a 0,60). |
⊕⊕◯◯1 Baja |
Realizar intervención psicológica 1 vez a la semana, comparado con una vez al mes, podría aumentar la efectividad de la terapia psicológica, pero la certeza de la evidencia es baja. |
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* La estimación de la pendiente del efecto (slope estimate) es una manera de estimar la probabilidad de que exista un efecto de subgrupo por medio de la técnica de regresión (o metarregresión). Una pendiente de 0% significa que no existe ninguna diferencia atribuible al subgrupo evaluado. A mayor valor, mayor probabilidad de que exista un efecto de subgrupo atribuible a la variable de interés. Si el intervalo de confianza para este valor pasa por el valor “0” significa que esta diferencia no es estadísticamente significativa.
1 Se disminuyó la certeza de la evidencia en dos niveles, ya que proviene de una comparación indirecta mediante análisis de regresión logística, y porque no proviene de estudios en adolescentes.
Fecha de elaboración de la tabla: Octubre, 2018.
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3. Baker AL, Kavanagh DJ, Kay-Lambkin FJ, Hunt SA, Lewin TJ, Carr VJ, Connolly J. Randomized controlled trial of cognitive-behavioural therapy for coexisting depression and alcohol problems: short-term outcome. Addiction (Abingdon, England). 2010;105(1):87-99.
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Búsqueda y Síntesis de Evidencia
Informe de búsqueda y síntesis de evidencia de los efectos deseables e indeseables
3.- ¿Qué tan significativos son los efectos indeseables anticipados?
| Grandes | Moderados | Pequeños | Triviales | Varía | No lo sé |
|---|
Triviales: El panel de expertos de la Guía estimó que los efectos indeseables de «realizar intervención psicológica con frecuencia 1 vez a la semana» en comparación a «realizar intervención psicológica con frecuencia 1 vez al mes» son triviales o no relevantes, considerando la evidencia y experiencia clínica.
Evidencia de investigación
FRECUENCIA 1 VEZ A LA SEMANA COMPARADO CON 1 VEZ AL MES PARA DEPRESIÓN EN MENORES DE 15 AÑOS.
Pacientes Personas menores de 15 años con diagnóstico de depresión.
Intervención Intervención psicológica con frecuencia 1 vez a la semana.
Comparación Intervención psicológica con 1 vez al mes.
|
Desenlaces |
Efecto* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
|
|
Efectividad |
Una revisión sistemática concluyó, mediante regresión logística, que había un aumento de la efectividad según frecuencia de sesiones. (Pendiente del efecto de 0,40 IC 95% 0,12 a 0,60). |
⊕⊕◯◯1 Baja |
Realizar intervención psicológica 1 vez a la semana, comparado con una vez al mes, podría aumentar la efectividad de la terapia psicológica, pero la certeza de la evidencia es baja. |
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* La estimación de la pendiente del efecto (slope estimate) es una manera de estimar la probabilidad de que exista un efecto de subgrupo por medio de la técnica de regresión (o metarregresión). Una pendiente de 0% significa que no existe ninguna diferencia atribuible al subgrupo evaluado. A mayor valor, mayor probabilidad de que exista un efecto de subgrupo atribuible a la variable de interés. Si el intervalo de confianza para este valor pasa por el valor “0” significa que esta diferencia no es estadísticamente significativa.
1 Se disminuyó la certeza de la evidencia en dos niveles, ya que proviene de una comparación indirecta mediante análisis de regresión logística, y porque no proviene de estudios en adolescentes.
Fecha de elaboración de la tabla: Octubre, 2018.
Referencias
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Búsqueda y Síntesis de Evidencia
Informe de búsqueda y síntesis de evidencia de los efectos deseables e indeseables
4.- ¿Cuál es la certeza general de la evidencia sobre efectos?
| Muy baja | Baja | Moderada | Alta | Ningún estudio incluido |
|---|
Baja: Existe cierta incertidumbre respecto del efecto de «realizar intervención psicológica con frecuencia 1 vez a la semana» en comparación a «realizar intervención psicológica con frecuencia 1 vez al mes». La certeza de la evidencia general se basa en la certeza del desenlace de salud de efectividad, dado que es el único reportado.
Evidencia de investigación
|
Desenlaces |
IMPORTANCIA |
Certeza de la evidencia (GRADE) |
|
Efectividad |
CRÍTICA |
⊕⊕◯◯1 Baja |
1 Se disminuyó la certeza de la evidencia en dos niveles, ya que proviene de una comparación indirecta mediante análisis de regresión logística, y porque no proviene de estudios en adolescentes.
5.- ¿Hay incertidumbre importante o variabilidad sobre qué tanto valora la gente los desenlaces principales?
| Incertidumbre o variabilidad importantes | Posiblemente hay incertidumbre o variabilidad importantes | Probablemente no hay incertidumbre ni variabilidad importantes | No hay variabilidad o incertidumbre importante |
|---|
Probablemente no hay incertidumbre ni variabilidad importantes: En función de la evidencia de investigación, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud, el panel de expertos de la Guía consideró que probablemente no hay incertidumbre o ni variabilidad importante respecto a lo que escogería una persona informada de los efectos deseables e indeseables de «realizar intervención psicológica con frecuencia 1 vez a la semana» y «realizar intervención psicológica con frecuencia 1 vez al mes». La mayoría de las personas escogerían 1 vez a la semana. Sin embargo, podría verse afectada la intención de asistir dada la disponibilidad de horario de los centros actualmente en Chile, que en lagunos casos no son compatibles con los horarios de trabajo de los papás. Los adolescentes a veces tiene que faltar a clases. También puede influir la ruralidad y el acceso
Evidencia de investigación
No se encontró evidencia respecto a valores y preferencias de personas menores de 15 años con diagnóstico de depresión respecto a realizar intervención psicológica con frecuencia 1 vez a la semana” en comparación a “realizar intervención psicológica con 1 vez al mes». Sin embargo, se identificó un estudio japonés (1) que evaluó la relación entre la frecuencia de la consultas psiquiátricas con la satisfacción hacia la consulta, percibida por 186 pacientes ambulatorios con depresión o ansiedad.
Las frecuencias de consulta fueron: 2% de los pacientes asistieron a la clínica dos o más veces por semana; 21% asistieron una vez por semana; 48% asistieron cada dos semanas; y 30% asistieron una vez cada varias semanas.
Conclusiones: En situaciones clínicas las consultas psiquiátricas densas están relacionadas mayor la satisfacción del paciente, medido como la percepción reportada por pacientes respecto al comportamiento del médico, en términos de: aceptación, centrado en el paciente, facilitación, atención. Por otro lado, el estudio identificó que la relación entre consultas densas y la disminución de la afectividad negativa está mediada por la satisfacción del paciente.
Referencias
1. Igarashi H, Kitamura T, Ohuchi K, Mitoma H. Consultation frequency and perceived consultation time in a Japanese psychiatric clinic: Their relationship with patient consultation satisfaction and depression and anxiety. Psychiatry Clin Neurosci [Internet]. 2008 Apr [cited 2018 Dec 13];62(2):129–34. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18412833
Búsqueda y Síntesis de Evidencia
Informe de búsqueda y síntesis de evidencia de las preferencias de los pacientes
6.- El balance entre efectos deseables e indeseables favorece la intervención o la comparación?
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | No lo sé |
|---|
Probablemente favorece la intervención: Considerando que la intervención es «realizar intervención psicológica con frecuencia 1 vez a la semana» y la comparación es «realizar intervención psicológica con frecuencia 1 vez al mes», el panel de expertos de la Guía opinó que el balance entre efectos deseables e indeseables probablemente favorece «realizar intervención psicológica con frecuencia 1 vez a la semana», en base a que la los efectos deseables son grandes, los indeseables triviales, que la certeza de la evidencia es baja y que probablemente no hay incertidumbre ni variabilidad importantes en los que escogerían los pacientes.
7.- ¿Qué tan grandes son los recursos necesarios (costos)?
| Costos extensos | Costos moderados | Costos y ahorros despreciables | Ahorros moderados | Ahorros extensos | Varía | No lo sé |
|---|
Costos moderados: El panel de expertos de la Guía consideró que los costos de «realizar intervención psicológica con frecuencia 1 vez a la semana» son moderados si se compara con los costos de «realizar intervención psicológica con frecuencia 1 vez al mes», en función de los antecedentes, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Evidencia de investigación
A continuación, se muestran los costos referenciales, es preciso considerar que estos costos fueron recogidos con el único objetivo de constituir un antecedente aproximado.
El porcentaje de cobertura del seguro de salud sobre el precio de las prestaciones sanitarias, dependerá del tipo de seguro de cada paciente.
|
Ítem |
Precio unitario |
|
Consulta psicólogo clínico (sesiones 45') 1 |
$ 11.870 |
|
Psicoterapia individual (sesiones 45')1 |
$ 13.700 |
|
1 vez a la semana (4 veces al mes) |
Rango: $11.870 a $13.700 |
|
1 vez al mes |
Rango: $47.480 a $54.800 |
Referencias
1. Precio total para prestador nivel 3 de la base de datos Modalidad de Libre Elección 2018, FONASA.
Búsqueda y Síntesis de Evidencia
Informe de búsqueda de costos referenciales de las intervenciones
8.- ¿La costo-efectividad de la intervención beneficia la intervención o la comparación?
| Favorece la comparación | Probablemente favorece la comparación | No favorece la intervención ni la comparación | Probablemente favorece la intervención | Favorece la intervención | Varía | Ningún estudio incluido |
|---|
Ningún estudio incluido: No se realizó la búsqueda de evidencia que abordaran la costo-efectividad ya que las intervenciones evaluadas no es consideraron de alto costo, según el Decreto 80 «Determinar umbral nacional de costo anual al que se refiere el artículo 6° de la Ley 20.850». Sin embargo, el panel considera que atender con mayor frecuencia podría prevenir la cronicidad, disminuyendo el tiempo de tratamiento y recursos asociados a éste (fármacos, derivación, hospitalizaciones en caso de recurrencias recaídas y comorbilidad asociadas).
9.- ¿Cuál sería el impacto en equidad en salud?
| Reducido | Probablemente reducido | Probablemente ningún impacto | Probablemente aumentado | Aumentado | Varía | No lo sé |
|---|
Aumentada: El panel de expertos de la Guía consideró que la equidad en salud aumentaría si se recomendase «realizar intervención psicológica con frecuencia 1 vez a la semana», dado que esta intervención está cubierto por el Régimen de Garantías Explícitas.
10.- ¿La intervención es aceptable para las partes interesadas?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Probablemente sí: El panel de expertos de la Guía consideró que «realizar intervención psicológica con frecuencia 1 vez a la semana» probablemente SÍ es aceptable para las partes interesadas (profesionales de la salud, gestores de centros de salud, directivos de centros de salud, pacientes, cuidadores, seguros de salud, otros). El panel agrega que las autoridades podrían estar focalizados en aumentar el ingreso a atención más que en la calidad de la atención. Por otro lado, adolescentes o cuidadores de zonas rurales o con restricción horaria por temas laborales o escolares podrían podrían preferir una menor frecuencia si es que no se lles dan las facilidades para asistir a la intervención.
11.- ¿Es factible implementar la intervención?
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Probablemente sí: El panel de expertos de la Guía consideró que «realizar intervención psicológica con frecuencia 1 vez a la semana» probablemente SÍ es factible implementar, depende de la disponibilidad de los recursos humanos, infraestructura, barreras de acceso de los servicios de cada red.