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Psicoterapias: ¿son útiles para tratar los trastornos mentales?

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Psicoterapias: ¿son útiles para tratar los trastornos mentales?. Amparo Belloch Fuster. Jornada de Presentación de la Estrategia en Salud Mental del Sistema Nacional de Salud (Madrid, Ministerio de Sanidad y Consumo, 2007)

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Psicoterapias: ¿son útiles para tratar los trastornos mentales?

  1. 1. Amparo Belloch Fuster Asociación Española de Psicología Clínica y Psicopatología
  2. 2. ESTRATEGIA EN SALUD MENTAL DEL SNS OBJETIVO GENERAL 4. Mejorar la calidad, la equidad y la continuidad de la atención a los problemas de salud mental. • 4.4. Aumentar el porcentaje de pacientes con trastornos mentales que reciben psicoterapia, acorde con las mejores prácticas disponibles.
  3. 3. “Aplicación intencionada e informada de métodos clínicos, basados en principios psicológicos bien establecidos, con la finalidad de ayudar a las personas a modificar sus comportamientos, cogniciones, y emociones de modo que resulten menos disfuncionales y más adaptativos de los que poseen” J.O. Prochaska y J.C.Norcross, 2003.
  4. 4. • Relación adecuada de interacción terapeuta-paciente • El paciente, agente activo en el proceso de cambio • Intervenciones programadas, objetivos explícitos – Promover cambios específicos (de comportamiento, de manejo de síntomas, de prevención y manejo de disparadores o mantenedores, de creencias y valoraciones sobre el significado del trastorno, de prevención de recaídas...) • Duración (pre)-determinada • Fundamentación psicológica (teórica y metodológica) consistente y reproducible
  5. 5. • No pautas prescriptivas: • Apoyo/Consejo breve intervenciones no • Sugestión programadas • “Training” • Objetivos genéricos • Consultoría – Relación difusa con causas • “Coaching” (psicológicas) del TM • Grupos autoayuda • Fundamentación escasa • Crecimiento y • No psico-educación desarrollo personal • No seguimientos • Talleres (autoestima, relajación, • No prevención de recaídas meditación,..) • Ausencia criterios cambio • ….. – Contrastación eficacia difícil
  6. 6. CONTENIDOS PARTICIPANTES Focalizada Individual: TM específicos Relación diádica paciente-terapeuta Amplia Grupal (5-8 pacientes, 1-2 Cambios globales en Terapeutas) el estilo de vida Abierto: Varios disfuncional, además pacientes con TM de reducir /eliminar diferentes síntomas. Cerrado/focalizado: Varios pacientes, mismo TM Familiar
  7. 7. TABLA 7. Prevalencia anual Trastornos de Ansiedad (ponderados para población española) (ESEMED) TRASTORNO TOTAL HOMBRES MUJERES Ansiedad Generaliz. 0,8 0,4 1,2 Fobia Social 0,6 0,6 0,6 1,2 Fobia Espec. 2,7 4,2 0,2 Estrés Post-Traum. 0,6 0,9 0,15 Agorafobia 0,4 0,6 Angustia 0,7 0,4 0,9 Cualquiera (IC 95%) 5,2 2,5 7,6 Estrategia en Salud Mental del SNS. 2006
  8. 8. Trastornos de Ansiedad más prevalentes 1º. 2º. TCE + EPR TCE + EPR Breve (6-10 ss.) >10 sesiones Individual o Grupo Individual 3º. TCE+EPR Y Farmacoterapia
  9. 9. Obsessive-compulsive disorder Clinical Guideline Published: November 2005
  10. 10. LEVE MODERADO GRAVE TC + EPR < 10 Horas (individual o grupo) Rehusa, no mejora, Ofrecer elección: o no se ajusta a la TC (+EPR, en su caso) TC (o a EPR) >10 horas R inadecuada o 12 semanas Tratamiento ISRS combinado TC (+EPR) Y ISRS
  11. 11. • Exposición (guiada, en vivo) + Prevención de Respuesta (bi-semanal) • Terapia Cognitiva ► ► ► 1ª si Depresión comórbida ) ÓN – Re-atribución: reality testing, prueba de H,… SI E ’ /S – Re-estructuración (PAL, Ellis) 5-60 al Beck n S (4 RU ma óG I - se – Re-educaci>n atencionalRA L O A L /B Albany,.. H DU 2í0 A VI – IProgramas espec ficos: Barlow, Clark, 10- AN IND N: SEM Ó I S : AC NE AD R O C ID ESI DU I E -S OD I •Sistémica S ENTR R PE A RE TA •Dinámica breve •Realidad Virtual
  12. 12. TABLA 6. Prevalencia anual de trastornos del Estado de Ánimo (ponderados para población española) (ESEMED) TRASTORNO TOTAL (%) HOMBRES (%) MUJERES (%) Episodio 3,9 2,2 5,6 Depresivo Mayor Distimia 1,5 0,52 2,4 Cualquiera 4,3 2,3 6,2 (IC 95%) Estrategia en Salud Mental del SNS. 2006
  13. 13. 1. COGNITIVA (Beck): 15-20 ss. (M=12) 2. CONDUCTUAL: 1. Actividades Agradables- Lewinsohn (12 ss.) 2. Habilidades sociales (12 ss.) 3. Grupo: CAD (Curso Afrontamiento Depresión) (12 ss.) 4. Solución de Problemas (8-12 ss.) 3. INTERPERSONAL (16 ss.) 4. SISTÉMICA 5. DINÁMICA BREVE
  14. 14. 2004 LEVE 1 PSICOTERAPIA BREVE (Cognitiva-Beck, Solución Problemas) MODERADA 2 PSICOTERAPIA AMPLIA (Cognitiva-Beck, Solución Problemas) ¿No mejoría ? Añadir ISRS GRAVE Y CRÓNICA 3 PSICOTERAPIA + ISRS
  15. 15. Bipolar disorder July 2006
  16. 16. Psicoterapia: NECESARIA si es accesible y el paciente está estable: • Individual • Estructurada • 16 sesiones entre 6-9 meses • Psicoeducación • Adherencia farmacoterapia • Auto-supervisión estado de ánimo, signos prodrómicos, estrategias prevención • Técnicas: estrategias de afrontamiento
  17. 17. PSICOTERAPIA COGNITIVO-CONDUCTUAL, TRATAMIENTO DE ELECCIÓN: • SOMATOFORMES (DOLOR, SOMATIZACIÓN) • HIPOCONDRÍA • ALIMENTARIOS • DISOCIATIVOS • FACTICIOS • CONTROL DE IMPULSOS • SEXUALES • DEL SUEÑO • DE PERSONALIDAD
  18. 18. E D SO CE AS IA CMP S ARA NO LOR E F E IG IO S A OT S AR TE IC OS ES EN PS ER EC CI DE IM N A S PR ES S P CE S LO ICA E LO EF SD E D
  19. 19. INDIVIDUAL • Cognitivo-conductual • Entrenamiento en para síntomas habilidades sociales positivos • Intervención familiar • Conductual para psico-educativa síntomas negativos
  20. 20. Psico-terapeuta cualificado (entrenamiento específico) Duración: 6-20 sesiones (45-60’, semanal) Evaluación del TM en términos de análisis funcional Combinación psico-educación sobre el trastorno y técnicas o estrategias específicas para promover cambios concretos Objetivos pre-definidos Metas terapéuticas consensuadas Duración y secuencia de las sesiones y del tratamiento Agenda (contenido) de las sesiones Tareas inter-sesión: entre 30-120’ Prevención de recaídas: 1-2 sesiones post-tratamiento das Evaluación continuada del progreso inter-sesiones Seguimientos: 12-24 meses post-prevención recaídas)
  21. 21. SON EFICACES PARA TRATAR LOS T.M. SON EL TRATAMIENTO DE ELECCIÓN PARA LOS T.M. MÁS PREVALENTES LA COMBINACIÓN PSICOTERAPIA + PSICOFÁRMACOS, ES EL TRATAMIENTO DE ELECCIÓN PARA LOS T.M. GRAVES LOS PSICÓLOGOS CLÍNICOS SON EXPERTOS EN PSICOTERAPIA: ES NECESARIO AUMENTAR EL NÚMERO DE PSICÓLOGOS CLÍNICOS EN EL SNS PARA QUE LOS CIUDADANOS TENGAN ACCESO A PSICOTERAPIAS EFICACES.
  22. 22. ESTRATEGIA EN SALUD MENTAL DEL SNS OBJETIVO GENERAL 4. Mejorar la calidad, la equidad y la continuidad de la atención a los problemas de salud mental. • 4.4. Aumentar el porcentaje de pacientes con trastornos mentales que reciben psicoterapia, acorde con las mejores prácticas disponibles.

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