Guía de Práctica Clínica - No GES
Trastorno Ansioso
r-t1-2018
En personas adultas con trastorno estrés postraumático (TEPT), el Ministerio de Salud SUGIERE agregar psicoterapia al tratamiento con inhibidores de la recaptura de serotonina (ISRS) por sobre solo utilizar inhibidores de la recaptura de serotonina.
Comentarios del panel:
►Si bien la mayoría de los pacientes se beneficiaría de agregar psicoterapia, algunas personas con estrés postraumático (por ejemplo, según fase del problema de salud, nivel de sintomatología, disponibilidad para asistir a psicoterapia y oferta especifica de psicoterapia) podrían beneficiarse solo de ISRS.
►Es importante destacar que esta patología podría tener sintomatología episódica y con alta tasa de abandono, por lo cual podría ser útil realizar medidas adicionales para mejorar la adherencia y la relación tratante-paciente.
►Además, existe variabilidad importante en las preferencias de los pacientes, dependiendo de sus experiencias con tratamientos previos, del tiempo de tratamiento, de la alianza terapéutica, entre otros factores.
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.
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
El problema ha sido definido como prioritario del Departamento de Salud Mental del Ministerio de Salud.
| Trivial | Pequeño | Moderado | Grande | Varía | No lo sé |
|---|
Grandes: El equipo elaborador de la Guía estimó que los efectos deseables de «agregar psicoterapia aI tratamiento con ISRS » en comparación a «solo utilizar ISRS» son grandes, considerando la evidencia, experiencia clínica, conocimiento de gestión o experiencia de las personas con la condición o problema de salud.
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
|
Terapia combinada comparado con ISRS para estrés postraumático. |
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|
Población |
Personas adultas con trastorno estrés postraumático (TEP). |
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|
Intervención |
Terapia combinada (psicoterapia + ISRS). |
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|
Comparación |
Inhibidores selectivos de recaptura de serotonina (ISRS). |
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|
Desenlaces |
Efecto relativo (IC 95%) — Estudios/ pacientes |
Efecto absoluto estimado* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
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|
ISRS |
Terapia combinada |
Diferencia (IC 95%) |
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|
Severidad de sintomatología de trastorno de estrés postraumático |
— 28 ensayos en una revisión sistemática [4] / 1256 pacientes |
DME**: 1,62 menos (1,21 a 2,03 menos) |
⊕⊕◯◯1,2,3 Baja |
La terapia combinada, en comparación con sólo ISRS, podría disminuir la severidad de la sintomatología de trastorno de estrés postraumático, pero la certeza de la evidencia es baja. |
||
|
Abandono (por cualquier razón) |
RR 1,45 (1,15 a 1,84) — 33 ensayos en una revisión sistemática [4] / 1756 pacientes |
131 por 1000 |
191 por 1000 |
Diferencia: 60 más (20 a 110 más) |
⊕⊕◯◯1,2 Baja |
La terapia combinada, en comparación con ISRS, podría aumentar el riesgo de abandono, pero la certeza de la evidencia es baja. |
IC 95%: Intervalo de confianza del 95%.
RR: Riesgo relativo.
DME: Diferencia de medias estandarizada.
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* El riesgo CON ISRS está basado en el riesgo del grupo control en los estudios. El riesgo CON Terapia combinada (y su intervalo de confianza) está calculado a partir del efecto relativo (y su intervalo de confianza).
** La diferencia de medias estandarizada se utiliza cuando el desenlace ha sido medido en diferentes escalas y es difícil de interpretar clínicamente. Una regla general es que valores menores a 0,2 son de poca relevancia clínica, valores de 0,5 de relevancia moderada y 0,8 relevancia clínica importante.
1 Se disminuyó un nivel de certeza de evidencia por riesgo de sesgo, ya que la mayoría de los ensayos no está clara la generación de secuencia de aleatorización ni ocultamiento de ésta. Además, ninguno de los ensayos fue ciego.
2 Se disminuyó un nivel de certeza de evidencia ya que no todos los ensayos utilizaron medicamentos basalmente (algunos psicoterapia versus no tratamiento) o algunos ensayos no discriminan, ni presentan los datos por separado, para este factor.
Fecha de elaboración de la tabla: Diciembre, 2018.
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106. Zang Y, Hunt N, Cox T. A randomised controlled pilot study: the effectiveness of narrative exposure therapy with adult survivors of the Sichuan earthquake. BMC psychiatry. 2013;13:41.
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Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
| Grande | Moderado | Pequeño | Trivial | Varía | No lo sé |
|---|
Varía: El equipo elaborador de la Guía consideró que existen componentes que pueden afectar de distinta manera los efectos indeseables de «agregar psicoterapia aI tratamiento con ISRS » en comparación a «solo utilizar ISRS».
Consideraciones Adicionales
El panel considera que el desenlace abandono es amplio, ya que puede explicarse por varias razones: Mejoría de sintomatología, efectos adversos, razones de pérdida de seguimiento (ej: cambio domicilio, pérdida del contacto), baja adherencia al tratamiento, entre otros. Por esta razón, estos resultados deben interpretarse con cautela.
Por lo tanto, el panel señala que el abandono no siempre se debe considerar como un resultado indeseable.
Por esto el panel considera que los efectos indeseables son variables para la terapia combinada.
Evidencia de investigación
Tabla de Resumen de Resultados (Summary of Findings)
|
Terapia combinada comparado con ISRS para estrés postraumático. |
||||||
|
Población |
Personas adultas con trastorno estrés postraumático (TEP). |
|||||
|
Intervención |
Terapia combinada (psicoterapia + ISRS). |
|||||
|
Comparación |
Inhibidores selectivos de recaptura de serotonina (ISRS). |
|||||
|
Desenlaces |
Efecto relativo (IC 95%) — Estudios/ pacientes |
Efecto absoluto estimado* |
Certeza de la evidencia (GRADE) |
Mensajes clave en términos sencillos |
||
|
ISRS |
Terapia combinada |
Diferencia (IC 95%) |
||||
|
Severidad de sintomatología de trastorno de estrés postraumático |
— 28 ensayos en una revisión sistemática [4] / 1256 pacientes |
DME**: 1,62 menos (1,21 a 2,03 menos) |
⊕⊕◯◯1,2,3 Baja |
La terapia combinada, en comparación con sólo ISRS, podría disminuir la severidad de la sintomatología de trastorno de estrés postraumático, pero la certeza de la evidencia es baja. |
||
|
Abandono (por cualquier razón) |
RR 1,45 (1,15 a 1,84) — 33 ensayos en una revisión sistemática [4] / 1756 pacientes |
131 por 1000 |
191 por 1000 |
Diferencia: 60 más (20 a 110 más) |
⊕⊕◯◯1,2 Baja |
La terapia combinada, en comparación con ISRS, podría aumentar el riesgo de abandono, pero la certeza de la evidencia es baja. |
IC 95%: Intervalo de confianza del 95%.
RR: Riesgo relativo.
DME: Diferencia de medias estandarizada.
GRADE: Grados de evidencia Grading of Recommendations Assessment, Development and Evaluation.
* El riesgo CON ISRS está basado en el riesgo del grupo control en los estudios. El riesgo CON Terapia combinada (y su intervalo de confianza) está calculado a partir del efecto relativo (y su intervalo de confianza).
** La diferencia de medias estandarizada se utiliza cuando el desenlace ha sido medido en diferentes escalas y es difícil de interpretar clínicamente. Una regla general es que valores menores a 0,2 son de poca relevancia clínica, valores de 0,5 de relevancia moderada y 0,8 relevancia clínica importante.
1 Se disminuyó un nivel de certeza de evidencia por riesgo de sesgo, ya que la mayoría de los ensayos no está clara la generación de secuencia de aleatorización ni ocultamiento de ésta. Además, ninguno de los ensayos fue ciego.
2 Se disminuyó un nivel de certeza de evidencia ya que no todos los ensayos utilizaron medicamentos basalmente (algunos psicoterapia versus no tratamiento) o algunos ensayos no discriminan, ni presentan los datos por separado, para este factor.
Fecha de elaboración de la tabla: Diciembre, 2018.
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Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de efectos deseables e indeseables
| Muy baja | Baja | Moderada | Alta | Ningún estudio incluido |
|---|
Baja: Existe cierta incertidumbre respecto del efecto de «agregar psicoterapia aI tratamiento con ISRS » en comparación a «solo utilizar ISRS».
Evidencia de investigación
|
Desenlaces |
Importancia |
Certeza de la evidencia |
|
Severidad de sintomatología de trastorno de estrés postraumático |
CRÍTICO |
⨁⨁◯◯ |
|
Abandono (por cualquier razón) |
IMPORTANTE |
⨁⨁◯◯ |
a. Se disminuyó un nivel de certeza de evidencia por riesgo de sesgo, ya que la mayoría de los ensayos no está clara la generación de secuencia de aleatorización ni ocultamiento de ésta. Además, ninguno de los ensayos fue ciego.
b. Se disminuyó un nivel de certeza de evidencia por indirecto ya que no todos los ensayos utilizaron medicamentos basalmente (alguna psicoterapia versus no tratamiento) o algunos ensayos no discriminan, ni presentan los datos por separado, para este factor
| Incertidumbre o variabilidad importantes | Posiblemente hay incertidumbre o variabilidad importantes | Probablemente no hay incertidumbre ni variabilidad importantes | No hay variabilidad o incertidumbre importante |
|---|
Posiblemente hay incertidumbre o 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 equipo elaborador de la Guía consideró que posiblemente existe incertidumbre o variabilidad importante respecto a lo que escogería una persona informada de los efectos deseables e indeseables de «agregar psicoterapia aI tratamiento con ISRS » y «solo utilizar ISRS».
Consideraciones adicionales.
El panel señala que su juicio se realizó considerando que la preferencia de las personas depende de la experiencia previa de tratamiento, del tiempo de tratamiento, entre otras.
Además, existe falta de información respecto a los objetivos específicos de las diferentes modalidades de la intervención.
Evidencia de investigación
Se identificó un estudio que exploró las razones por las cuales las personas preferían terapia cognitivo conductual o tratamiento farmacológico con inhibidores selectivos de recaptación de serotonina (ISRS).
Los objetivos del estudio fueron: examinar cualitativamente las razones de los individuos sobre su preferencia de tratamiento, examinar si determinados tipos de razones estaban más asociadas con la preferencia por la psicoterapia cognitiva conductual o la medicación (sertralina) y examinar si las diferencias individuales (características demográficas, historial de tratamiento previo, gravedad de la psicopatología) predijeron las razones de su elección.
Usando una muestra de búsqueda de tratamiento (N = 200) con trastorno de estrés postraumático crónico, se examinaron las razones cualitativas que subyacen a las preferencias de tratamiento. Las razones para la preferencia de tratamiento se centraron principalmente en cómo se percibía el tratamiento para reducir los síntomas de trastorno de estrés post traumático.
En promedio, los participantes tenían 37,4 años de edad (SD=11,3). La muestra reportó variedad de traumas: asalto sexual en adultos (31.0%), asalto no sexual en adultos (22.5%), asalto infantil (24.0%), accidente (13.5%), muerte de/violencia a un ser querido (6.5%), y combate/guerra (2.5%).
En general, los individuos reportaron preferencia por la terapia cognitivo conductual (57.0%, n = 114) por sobre sertralina (42.0%, n = 84).
En conjunto, esta información es fundamental para los proveedores de tratamiento, ya que aboga por mejorar la psicoeducación acerca de cómo funciona el tratamiento, reconociendo los prejuicios preexistentes contra la farmacoterapia, que deben abordarse.
1. Chen JA, Keller SM, Zoellner LA, Feeny NC. «How will it help me?» Reasons underlying treatment preferences between sertraline and prolonged exposure in posttraumatic stress disorder. J Nerv Ment Dis. 2013 Aug; 201(8):691-7.
Búsqueda y Síntesis de Evidencia
Búsqueda y síntesis de evidencia de valores y preferencias de los pacientes
| 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 «agregar psicoterapia aI tratamiento con ISRS » y la comparación es «solo utilizar ISRS», el equipo elaborador de la Guía opinó que el balance entre efectos deseables e indeseables probablemente favorece «agregar psicoterapia aI tratamiento con ISRS «.
| Costos extensos | Costos moderados | Costos y ahorros despreciables | Ahorros moderados | Ahorros extensos | Varía | No lo sé |
|---|
Costos moderados: El equipo elaborador de la Guía consideró que los costos de «agregar psicoterapia aI tratamiento con ISRS » son moderados si se compara con los costos de «solo utilizar ISRS», en función de los antecedentes, experiencia clínica, conocimiento de gestión o experiencia de los pacientes.
Consideraciones Adicionales
El panel señala que es importante considerar que el sector privado los costos de las intervenciones son mayores.
Evidencia de investigación
|
Trastorno Estrés Postraumático |
|||
|
Intervención |
Antidepresivos ISRS + psicoterapia |
ISRS |
Proveedor Privado |
|
Fluoxetina 20 Mg1 |
$34-$151 |
$34-$151 |
—– |
|
Paroxetina 20 Mg1 |
$361 |
$361 |
—– |
|
Escitalopram 10 Mg1 |
$481 -$1224 |
$48 -$1224 |
—– |
|
Sertralina 100 Mg1 |
$521 – $4014 |
$521 – $4014 |
—– |
|
Sertralina 50 Mg1 |
$84 -$171 |
$84 -$171 |
—– |
|
Citalopram 20 Mg1 |
$691 |
$691 |
—– |
|
Escitalopram 20 Mg1 |
$1081 |
$1081 |
—– |
|
Venlafaxina 75 Mg1 |
$364 -1521 |
$364 -1521 |
—– |
|
Consulta O Control Por Psicólogo Clínico2 |
$3.060 |
—– |
—– |
|
Mirtazapina 15 mg cm |
$2501 – $407 4 |
$2501 – $407 4 |
—– |
|
Consulta O Control Médico Integral En Atención Primaria2 |
$4.710 |
—– |
$30.280 (Médico General) |
|
Consulta De Salud Mental Por Otros Profesionales2 |
$3.060 |
—– |
—– |
|
Consulta De Psiquiatría2 |
$7.800 |
—– |
—– |
|
Consulta Médica De Especialidad En Psiquiatría Adultos (1ra Consulta) 3 |
$26.930 |
—– |
$33.960 |
|
Consulta Psicólogo Clínico (Sesiones 45′)3 |
$11.870 |
|
$30.280 |
|
Total Rango Precio Por Comprimido: |
$15 – $401 |
$15 – $401 |
—– |
|
Total Rango Terapias |
$3.060 – $26.930 |
—– |
$30.280 – $33.960 |
Tabla. Precios referenciales*
1. Precio de compra por Establecimientos de Salud Públicos a través de plataforma Mercado Público, al 2018. Precio incluye IVA.
2. MAI
3. MLE
4. Estudio de Verificación de Costos 2015
5. Arancel Clínica Dávila, revisado https://www.davila.cl/aranceles/ , el 10/12/2018
Búsqueda y Síntesis de Evidencia
Búsqueda de costos
| 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 |
|---|
Probablemente favorece la intervención: Considerando que la intervención es «agregar psicoterapia aI tratamiento con ISRS » y la comparación es «solo utilizar ISRS», el equipo elaborador de la Guía opinó que probablemente la alternativa más costo-efectiva es «agregar psicoterapia aI tratamiento con ISRS «.
Evidencia de investigación
No se realizó la búsqueda de estudios que abordaran la costo-efectividad de esta intervención ya que no es considerado un tratamiento de alto costo (1).
1. Anual $2.418.399 y Mensual $201.533. Ministerio de Salud. Decreto 80: Determinar umbral nacional de costo anual al que se refiere el artículo 6° de la Ley 20.850 [Internet]. Santiago; 2015 Nov.
| Reducido | Probablemente reducido | Probablemente ningún impacto | Probablemente aumentado | Aumentado | Varía | No lo sé |
|---|
Reducida: El equipo elaborador de la Guía consideró que la equidad en salud se reduciría si se recomendase «agregar psicoterapia aI tratamiento con ISRS «, dado que identificó grupos o contextos que actualmente tiene barreras de acceso importantes, ya sea en términos económicos, geográficos u otros.
Consideraciones Adicionales
El problema de salud no está financiado por el sistema de salud, por lo tanto alguna población tendria mayores dificultades para acceder a la intervención.
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Varía: El equipo elaborador de la Guía considera que existen componentes que pueden afectar de distinta manera la aceptación de la intervención “agregar psicoterapia aI tratamiento con ISRS » por las partes interesadas (profesionales de la salud, gestores de centros de salud, directivos servicios de salud, pacientes, cuidadores, seguros de salud, otros).
Consideraciones Adicionales
El panel destaca que la variabilidad depende de las partes interesadas, de los tomadores decisiones y de los pacientes.
| No | Probablemente no | Probablemente sí | Sí | Varía | No lo sé |
|---|
Probablemente sí: El equipo elaborador de la Guía consideró que «agregar psicoterapia aI tratamiento con ISRS » probablemente SÍ es factible implementar, contemplando la capacidad de la red asistencial, los recursos humanos disponibles a nivel país, recursos financieros, etc.