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Guía de Práctica Clínica - No GES

Para el abordaje de Depresión en Adolescentes

ETD6

En adolescentes con diagnóstico de depresión, el Ministerio de Salud SUGIERE realizar al menos 12 sesiones de intervenciones psicológicas.
Comentarios del Panel de Expertos:
►La mayoría de los adolescentes se beneficiarían de 12 sesiones de intervención psicológica. Sin embargo, el número de sesiones óptimo depende del cuadro clínico, los objetivos terapéuticos y las características del adolescente, su familia y contexto.
►La frecuencia y el número de sesiones de intervenciones psicológicas son variables interrelacionadas (Ver recomendación sobre frecuencia de sesiones).
►Si bien las primeras sesiones consideran la evaluación diagnóstica y establecer alianza terapéutica, es importante realizar intervenciones terapéuticas desde el inicio para optimizar el tratamiento.
►Para la decisión de egreso del adolescente, es importante considerar el logro de los objetivos terapéuticos propuestos en el plan de intervención.

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 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

Varía: El panel de expertos de la Guía consideró que existen componentes que pueden afectar de distinta manera los efectos deseables de «realizar al menos 12 sesiones de intervenciones psicológicas» en comparación a «realizar menos de 12 sesiones». El número de sesiones óptimo depende de los objetivos terapeúticos y las características del adolescente y su familia. Sin embargo, se debe considerar que en las primeras sesiones se debe realizar la evaluación y establecer la alianza terapéutica.

Evidencia de investigación

MÁS DE 12 SESIONES COMPARADO CON MENOS DE 12 SESIONES PARA DEPRESIÓN EN MENORES DE 15 AÑOS.
Pacientes Personas menores de 15 años con diagnóstico de depresión.
Intervención Realizar 12 sesiones de intervención psicológica.
Comparación Realizar menos de 12 sesiones de intervención psicológicas.

Desenlaces

Efecto*

Certeza de la evidencia

(GRADE)

Mensajes clave en términos sencillos

Efectividad

Una revisión sistemática concluyó, mediante regresión logística, que no había aumento de la efectividad según número de sesiones. (Pendiente del efecto de 0,011 IC 95% 0 a 0,023) [1].

⊕⊕◯◯1

Baja

Realizar 12 sesiones de intervención psicológica, comparado con menos de 12 sesiones podría tener poco o nulo impacto en 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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Búsqueda y Síntesis de Evidencia

 3.- ¿Qué tan significativos son los efectos indeseables anticipados?
Grandes Moderados Pequeños Triviales Varía No lo sé

Varía: El panel de expertos de la Guía consideró que existen componentes que pueden afectar de distinta manera los efectos indeseables de «realizar al menos 12 sesiones de intervenciones psicológicas» en comparación a «realizar menos de 12 sesiones». Prolongar el número de sesiones sin que esté asociado a un objetivo de tratamiento puede aumentar el riesgo de que los adolescentes y sus familia abandonen la intervención. El número de sesiones debería ser coherente con los objetivos y plan de tratamiento.

Evidencia de investigación

MÁS DE 12 SESIONES COMPARADO CON MENOS DE 12 SESIONES PARA DEPRESIÓN EN MENORES DE 15 AÑOS.
Pacientes Personas menores de 15 años con diagnóstico de depresión.
Intervención Realizar 12 sesiones de intervención psicológica.
Comparación Realizar menos de 12 sesiones de intervención psicológicas.

Desenlaces

Efecto*

Certeza de la evidencia

(GRADE)

Mensajes clave en términos sencillos

Efectividad

Una revisión sistemática concluyó, mediante regresión logística, que no había aumento de la efectividad según número de sesiones. (Pendiente del efecto de 0,011 IC 95% 0 a 0,023) [1].

⊕⊕◯◯1

Baja

Realizar 12 sesiones de intervención psicológica, comparado con menos de 12 sesiones podría tener poco o nulo impacto en 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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Búsqueda y Síntesis de Evidencia

 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 al menos 12 sesiones de intervenciones psicológicas» en comparación a «realizar menos de 12 sesiones». La certeza de la evidencia general se basa en la certeza del desenlace de salud efectividad, dado que es el único reportado y fue considerado crítico para los pacientes.

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

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 panel de expertos 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 «realizar al menos 12 sesiones de intervenciones psicológicas» y «realizar menos de 12 sesiones». La motivación al tratamiento, edad y el contexto social del adolescente y su familia podría incidir en las preferencias de aumentar o no el número de sesiones. Muchos adolescentes dependen de otros personas para asistir a las sesiones.

Evidencia de investigación

No se encuentras estudios que evalúen los valores y preferencias de personas menores de 15 años con diagnóstico de depresión respecto a realizar 12 sesiones de intervención psicológica en comparación a realizar menos de 12 sesiones de intervención psicológicas.

Búsqueda y Síntesis de Evidencia

 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

Varía: El panel de expertos de la Guía consideró que existen componentes que pueden afectar de distinta manera el balance entre efectos deseables e indeseables, considerando que los efectos deseables e indeseables varían, que la certeza de la evidencia es baja y que posiblemente hay incertidumbre o variabilidad importantes en lo 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 y ahorros despreciables: El panel de expertos de la Guía consideró que los costos y ahorros de «realizar al menos 12 sesiones de intervenciones psicológicas» son despreciables si se compara con «realizar menos de 12 sesiones», 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

12 sesiones

Consulta psicólogo clínico (sesiones 45') 1

$ 11.870

$ 142.440

Psicoterapia individual (sesiones 45')1

$ 13.700

$ 164.400

Consulta o control por psicólogo clínico2

$ 3.230

$ 38.760

Consulta de salud mental por otros profesionales2

$ 3.230

$ 38.760

Referencias

1. Precio total para prestador nivel 3 de la base de datos Modalidad de Libre Elección 2018, FONASA.
2. Precio total para obtenida de la base de datos Modalidad de Atención Institucional 2018, FONASA.

Búsqueda y Síntesis de Evidencia

 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 estima que la costo-efectividad puede variar en función de lo indicado en efectos indeseables y deseables.

 9.- ¿Cuál sería el impacto en equidad en salud?
Reducido Probablemente reducido Probablemente ningún impacto Probablemente aumentado Aumentado Varía No lo sé

Varía: El panel de expertos de la Guía considera que existen componentes que pueden afectar de distinta manera el impacto en equidad en salud de recomendar «realizar al menos 12 sesiones de intervenciones psicológicas». En pacientes que se atienden en la atención primaria de salud, su acceso depedende de la oferta local de sesiones de intervenciones psicológicas. Por otro lado, adolescentes con seguro de salud privado podrían tener restricciones económicas.

 10.- ¿La intervención es aceptable para las partes interesadas?
No Probablemente no Probablemente sí Varía No lo sé

Varía: El panel de expertos de la Guía considera que existen componentes que pueden afectar de distinta manera la aceptación de la intervención “realizar al menos 12 sesiones de intervenciones psicológicas» por las partes interesadas. Varía en función de las preferencias del adolescentes y sus familiares, de la red de salud en la que se atiende y del profesional que realiza la intervención psicólogica. Además, depende del cumplimiento de los objetivos de tratamiento.

 11.- ¿Es factible implementar la intervención?
No Probablemente no Probablemente sí Varía No lo sé

Sí: El panel de expertos de la Guía consideró que «realizar al menos 12 sesiones de intervenciones psicológicas» SÍ es factible implementar, contemplando que los establecimientos de atención primaria tienen una oferta limitada, han logrado mejorar su cobertura haciendo más eficiente su gestión de casos y utilizando diversas estrategias de abordaje.