Objectives: the present work aims at analysing the reality of the assistance offered to patients with depressive disorders through an observational study with descriptive and comparative strategies. More specifically, the objectives of this study are: to assess the characteristics of evidence based treatments in healthcare settings; it’s effectivity at reducing depressive symptoms and other related variables; and it’s efficiency.
Method: this work constitutes a retrospective and archival study that collects the results of psychological treatments that took place in a natural setting, which were followed up in a longitudinal fashion. An intentional sample of 89 cases diagnosed with either Major Depressive Disorder (80,9%) or Dysthymia (19,1%) at the “Clínica Universitaria de Psicología” [University Psychology Clinic] of the UCM was gathered. 78,7% of all cases were women, and 48,3% were undergoing pharmacological treatment; average length of current episode was 30,9 months, and average score on the BDI-II was 33 points. Several demographic, clinical and treatment variables were recorded to address the objectives of the study.
Results: patients received individualized, self-corrective treatments based upon psychoeducation, cognitive restructuring, behavioural activation, relaxation techniques, problem solving and social skills training, among other techniques up to a mean number of seven techniques, during 18 weekly sessions on average. A 35,96% of all patients terminated the intervention prematurely, with adherence to sessions and techniques and the global severity index of the SCL-90-R significantly associated to dropout. Treatments that ended prematurely were shorter and comprised fewer techniques in a significant way. Of the total sample, 80,3% patients reached a clinically significant change in depressive symptoms measured with the BDI-II, 86,2% with the BAI. The amount of reduction on BDI-II scores was
related to the use of social skills training; moreover, more severely disturbed patients and those diagnosed through BDI-II and clinical judgement had a better improvement. Younger patients, those with lower pre-treatment scores on the BAI and the global severity index of the SCL-90-R, and those with better functioning, assessed through the GAF, reached remission with a significantly higher chance.
Treatment was cost-effective related to pharmacological treatment delivered at Primary Care; specifically, direct average costs of increasing in 1% the amount of the treated sample that reached remission in Primary Care was 34,9% (considering just treatment) or 11,0% (considering assessment and treatment) higher than that of the evidence based psychological treatment.
Discussion: it is confirmed in the present study that treatments delivered at a healthcare setting with an evidence based clinical practice approach are equivalent in length, techniques and “dosage” to the empirically supported treatments, specially Beck’s cognitive therapy, although additional components are included on the basis of clinical judgement; in the case of relaxation techniques and problem solving training, they don’t seem to increase improvement in a significant manner. It’s not possible to reliably assess the effect of cognitive restructuring and behavioural activation; therefore, there is room for treatment reduction and cost- effectiveness improvement.
Treatment’s effectivity, based upon the contrast with effect sizes and improvement ratios, was as good as or better than other treatments in healthcare or research settings, with a high dropout rate, but consistent with that found at other university settings. Theses results were not affected by potentially confounding variables as the payment of a reduced fee for the members of the university community, the use of adjunctive pharmacological treatment, or the diagnosis of Dysthymia versus Major Depressive Disorder. On the other hand, the diagnostic procedure, whether it was SCID or clinical judgement, did produce differences.
The lack of a significant effect of treatment duration, and the evidence that patients that prematurely terminated interventions did nonetheless benefit from them is consistent with a “good enough level” (GEL) model, which states that patients undergo treatment until they decide that they have improved enough related to objective and subjective costs of treatment.
Generalizability of the results of this study is high according to standardized criteria. Among the limitations of this study are the lack of long term follow up for many cases, the high amount of missing values among post treatment measures – which is nonetheless common in healthcare clinical practice; and the archival nature of the study, which precludes the use of adequate experimental controls and hence might hamper it’s internal validity.
Conclusions: this study supports the empirical evidence on the effectivity of evidence – based treatment of depressive disorders in healthcare settings. Patients’ change pattern seems consistent with the seeking of a good enough level.
Additionally, evidence-based psychological intervention was more expensive, but also more cost-effective, regarding direct healthcare costs, than treatment delivered in Primary Care settings. Moreover, there is room for further increase of its efficiency, positioning evidence based psychological treatment as a highly competitive treatment option.
From these results, the prolongation of psychological treatments until improvement is reached, while the objective and subjective costs of the intervention are considered, it’s recommended, as is the use of clinical case formulation as a way of reducing treatment’s length, getting rid of superfluous elements and emphasizing instead the interpersonal themes of depression.
Regarding future studies, the development of measure tools that promote adherence to its use and longitudinal follow up, and the use of multivariate methods to identify dropout and improvement predictors, are encouraged.
Keywords: depression: evidence based practice; effectivity; cost-effectiveness; moderating variables.