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RESUMEN Este trabajo pretende conocer el impacto que los tratamientos basados en la evidencia (TBE) ejercen sobre la psicología aplicada, así como los factores que podrían estar relacionados con dicho impacto. La muestra estuvo compuesta por 242 psicólogos formados en España, a los que se les administró un cuestionario ad hoc constituido por preguntas que recogían información acerca de determinadas variables sociodemográficas y sobre el uso o conocimiento de los TBE para los trastornos mentales en población adulta. Los resultados señalan que, a excepción de las terapias cognitivo-conductuales, el impacto de los tratamientos basados en la evidencia es limitado, pudiendo influir en dicho impacto el tipo de acreditación profesional y los años de experiencia clínica. Los hallazgos de este estudio apoyan la idea de que los resultados de la investigación no se implementan ni consolidan del todo en los ámbitos aplicados. ABSTRACT This paper aims to know the impact of evidence-based treatments (EBTs) on applied psychology, as well as the factors that could be related to this impact. The sample consisted of 242 psychologists trained in Spain, who were administered an ad hoc questionnaire consisting of questions that gathered information about certain sociodemographic variables and about the use or knowledge of EBTs for mental disorders in adults. The results indicate that, with the exception of cognitive-behavioral therapies, the impact of EBTs is limited, and the professional accreditation and the years of clinical experience may influence this impact. The findings of this study support the idea that the results of the research are not fully consolidated in applied areas.

Nowadays there is a wide variety of psychological interventions to treat mental disorders, meaning that professionals have to weigh up which one is more effective to reach the therapeutic objectives. In this sense, during the last decades, explicit criterio have been established to determine whether a treatment is effective or not. The scientific evaluation of psychological treatments began to be systematized in the mid-twentieth century, reaching its peak during the 1980s and 1990s with the appearance of numerous randomized controlled trials (RCTs) and meta-analyzes. The proliferation of quality studies led to the emergence of a series of organizations aimed to review and disseminate those treatments supported by research and made existing institutions such as the American Psychological Association (APA) also pursue that goal. Between 1995 and 1998, a task force of the Division 12 (Society of Clinical Psychology) of the APA published several reports that identified treatments with empirical support and proposed the criteria that could be used to determine if a treatment is effective. These reports were published for Psychology students to be trained in therapies with demonstrated efficacy, and to inform practicing clinical psychologists, health insurers, and the public in general, about the existence of these treatments. Possibly, the most relevant contributions of the lists of effective treatments were establishing the explicit criteria that allow assessing the quality of the evidence of the interventions and the creation of institutions acting as mediators between research and clinical practice, serving as a reference and as a source of consultation for clinicians and academics. However, the systems used to determine the evidence for each intervention vary between institutions. In fact, they usually follow different assessment criteria, which suggests that the recommendations may differ from one organization to another. In addition, despite the endeavors made by different organizations to transfer the information provided by the research to the different actors involved, numerous studies have suggested that the knowledge held by psychologists concerning evidence-based treatments (EBTs) may be limited, suggesting that there is a need for more training, dissemination and implementation of these treatments. Some of the proposals made to improve the dissemination of these treatments among applied psychologists suggest the adaptation of the interventions to real situations of application and promoting the training of these professionals in the psychological treatment from a transdiagnostic perspective. An example of this matter may consist in developing intervention protocols composed of less than 10 sessions. This treatment modality is not sufficiently represented in the recommendations of the main organizations, but it is often applied in public and private settings in an unstructured or improvised manner. Regarding the use of a transdiagnostic treatment, its implementation would benefit clinical practice, since it may allow developing treatment modules that could be used in patients with different diagnoses or problems, which may allow avoiding that psychologists have to be trained in numerous and complex specific treatments for each disorder. Under this situation several objectives have been proposed. To accomplish them, this doctoral thesis, composed of four independent but intertwined studies, was conducted. The first study gathered the recommended EBTs for mental disorders in adults by different organizations in order to determine the level of existing agreement. To that end, the recommendations proposed by Division 12 of the APA, the National Institute for Health and Care Excellence (NICE), the Cochrane Collaboration and the Australian Psychological Society (APS) were reviewed following the PRISMA methodology for systematic reviews. A total of 135 treatments for 23 mental disorders were compiled and the degree of similarity among the recommendations proposed by each organization was analyzed. Results showed that the agreement among institutions was low for most of the disorders, observing discrepancies in the evidence presented by each one of them. These discrepancies might be due to a combination of reasons: possible biases in the procedures or in the evaluation committees, different studies reviewed by each organization to recommend a certain treatment, the use of different criteria to graduate the level of evidence, and the reviews of existing evidence were conducted in different time periods. The second study shares the aims of the previous study but focused on children and adolescents. For this, following the PRISMA methodology, the same organizations reviewed in Study 1 were analyzed, with the exception that the recommendations proposed by Division 53 (Society of Clinical Child and Adolescent Psychology) of the APA were used instead of the proposed by Division 12. A total of 137 treatments for 17 mental disorders were compiled and the degree of agreement among the recommendations proposed by each organization was examined. Results were similar to those obtained in study 1. A low agreement for most of the disorders was observed, and the same discrepancies discussed above were found. The third study aimed to determine the impact that EBTs have on the clínical practice of psychologists trained in Spain. In order to achieve this objective, a retrospective single-group ex post facto study was designed. Results confirmed that the use of EBTs by psychologists is limited, highlighting cognitive-behavioral therapies above other treatments. After analyzing some possible personal variables that could explain the use of EBTs, results indicated that the type of professional accreditation and the years of clinical experience could be related to the use of EBTs. Finally, the fourth study was directed to designing a protocol of an RCT in which the efficacy of a brief therapy adaptation of the "Unified Protocol for the transdiagnostic treatment of emotional disorders" will be examined. For this, an RCT was developed with five groups (brief therapy based on the Unified Protocol; conventional psychological treatment; conventional psychological treatment plus pharmacological therapy; mínimum intervention based on basic psychoeducational information, counseling and bibliotherapy; and usual pharmacological treatment), which would be carried out in public health centers. In this way, brief therapy will be compared with other treatment modalities frequently used in the public health system. The protocol follows the recommendations for intervention trials proposed in the SPIRIT statement -Standard Protocol Item: Recommendations for Interventional Trials-, and the rules for the communication of the trials proposed in the CONSORT statement -Consolidated Standards of Reporting Trials-. The findings of this RCT will be described in future publications, since due to the time limit for the development of this doctoral thesis, only the design of the trial and the start of its implementation were proposed as a plausible goal. In conclusion, there are significant differences among the psychological treatments recommended by the organizations included in this work due to the use of different procedures to evaluate and grade the quality of the evidence. In addition, despite the effort made by these institutions to disseminate the results of scientific research among applied professionals, it has been demonstrated that the divulgation of these findings has not been sufficiently successful among Spanish psychologists. Finally, with the aim of testing an intervention that fits the realities of healthcare public services, the protocol for a brief intervention under a transdiagnostic approach has been designed to be carried out in public health centers. In the case that the results of the study were favorable, including this type of therapies would decongest the healthcare system.

Premio extraordinario de Trabajo Fin de Máster curso 2019/2020. Máster en Psicología General Sanitaria Numerosas investigaciones han explorado los efectos de la exposición indirecta al trauma y al sufrimiento en profesionales del ámbito sanitario. Sin embargo, resulta llamativa la escasez de estudios centrados específicamente en la figura del psicólogo. La concurrencia de factores de riesgo ocupacionales y personales, junto con barreras como los estereotipos y expectativas sobre los psicólogos, constituyen un caldo de cultivo para el desarrollo de problemas psicoemocionales que pueden dar lugar, en último término, a mala praxis profesional que repercute negativamente en la salud mental de los usuarios. Así, aunque hay muchas investigaciones realizadas en este ámbito, son muy pocas las que están centradas en psicólogos, por lo que nos planteamos explorar esta cuestión a través de una revisión sistemática y metaanálisis. Se incluyeron en la revisión 51 estudios que incluían medidas de los tres constructos asociados al coste del cuidado: fatiga por compasión, estrés traumático secundario y traumatización vicaria. Los resultados mostraron que, si bien de modo general se observa un nivel de afectación baja, en torno al 20% de los profesionales que dispensan atención psicológica en contextos de alto sufrimiento presentan síntomas compatibles con un diagnóstico de TEPT, un riesgo moderado de fatiga por compasión, y trauma vicario en rangos subclínicos. La heterogeneidad de los estudios no permite establecer conclusiones sólidas, aunque parece que existen factores de riesgo personales, organizacionales y laborales que pueden incrementar la vulnerabilidad para desarrollar estas condiciones y su severidad, si bien la satisfacción que genera dispensar atención psicológica parece ser un potente factor de protección. Several studies have explored the effects of indirect exposure to trauma and suffering in healthcare professionals. However, there is a lack of evidence concerning this impact among psychologists. The confluence of occupational and personal hazards, along with barriers such as stereotypes and expectations that hinder help-seeking behaviours, make up a breeding ground for the development of psycho-emotional issues that may entail harmful practices towards clients. Although these conditions have been thoroughly studied in different settings and occupations, serious doubts have been casted upon their validity due to recurrent methodological and conceptual issues. Thus, owing to these concerns, and due to the amount of studies conducted in this context, but the paucity of research focused on the figure of the psychologist, this work aims to explore this matter through a systematic review and a meta-analysis. Fifty-one papers including quantitative measures of the three constructs of the literature regarding the cost of caring (compassion fatigue, vicarious trauma, and secondary traumatisation) were analysed. Results showed a mild level of impairment among the samples, a moderate risk for compassion fatigue, and subclinical range for vicarious trauma. However, around 20% of professionals providing psychological support present symptoms compatible with a PTSD diagnosis, and around 5% disruptions in their cognitive schemas regarding personal safety. The heterogeneity of the studies did not allow solid conclusions to be drawn, although it seems that there are certain risk factors (personal and occupational) that may increase the vulnerability for developing these conditions and worsening their severity. Still and all, the satisfaction these professionals experience resulting from their jobs is highlighted in all the studies as a protective of the deleterious impact of exposure to human suffering.

Emotional disorders (EDs), that mainly include anxiety and depressive diagnoses, are extremely prevalent worldwide. Patients with EDs do not only present affective or mental symptoms, but also have multiple limitations and difficulties in several vital areas such as work, family or social life. They present high comorbidity between them and they are the leading cause of disabilities. It is estimated that one out of six people may be suffering from an ED. Moreover, studies show how the numbers have been increasing during the last decades and they are expected to grow more in the near future. Public health systems face, therefore, the challenging task of providing efficient treatments for an exponential number of patients. However, around the half of the patients with EDs do not receive any treatment or the one they receive is not the appropriated one. This is mainly due to the fact that most of the patients with anxiety and/or depression are treated in Primary Care (PC) services, where there is not usually available any type of psychological intervention. In fact, the treatment with psychotropic drugs (mainly anxiolytics, hypnotics and antidepressants) is, by far, the most frequent for these disorders, which contradicts the recommendations of scientific research and international clinical guidelines, which point to psychological therapy as treatment of choice. Even when patients are referred to Specialized Care, the huge number of consultations and the lack of time make it impossible to follow the current manualized psychological treatment protocols. Consequently, patients with EDs do not receive the correct interventions either in this second level of attendance. All these issues in the treatment of ED carry serious consequences. In the first place, the excessive prescription of psychotropic drugs leads to addiction disorders, accidents and, in some cases, the chronification of the symptoms. Secondly, the healthcare pressure is increased when patients do not find relief for their mental problems and they consul repeatedly in PC. And last, but not least, there are exorbitant expenses due to the unreasonable prescription of medication along with the sick leaves and disabilities associated with EDs. For these reasons, new psychological therapies that might allow the effective treatment of EDs are being developed in recent years. On the one hand, the transdiagnostic approach would help to minimize the comorbidity issue, since it is design to target the underlying and shared mechanisms of all EDs. These transdiagnostic treatments would reduce the number of different interventions that clinicians need to learn and apply. Instead, only one protocol can be used for the whole set of anxiety and depressive problems. In this sense, the Unified Protocol developed by Barlow and their colleagues is one the most evidence-based transdiagnostic treatments for EDs and it has demonstrated to be as effective as other psychological specific-disorder interventions. On the other hand, brief therapies attempt to reduce the time needed to archive significant clinical changes. It appears that there is certain consensus that these therapies should have more than two and less than ten sessions. They have proven to be effective for anxiety and depressive disorders as some authors claim that they are just as effective as traditional and extensive psychological treatments. In fact, although more research is needed, they have already been successfully applied in some PC settings. By combining these two lines of action within health systems, more patients with EDs could be treated effectively in less time. In addition, other strategies are being considered as delivering psychological interventions in a group format, as part of a collaborative care or as part of a stepped care program. Despite there are some promising evidences of their effectiveness, the acceptability among patients and professionals of these last proposals seems to be questionable. Within this framework, several objectives were proposed in this doctoral thesis. To accomplish them four independent but intertwined studies were conducted. The first study was a meta-analysis that gathered the available information about brief therapies applied in PC for EDs compared with pharmacological interventions. Following PRISMA methodology, a systematic search was conducted in Medline, Embase and PsycInfo databases. We selected 33 randomized controlled trials (RCTs) that involved a total of 3868 patients. Results indicated a moderate effect size favourable to brief therapies at post-treatment (d = 0.37), but this was not maintained at follow-up. Therefore, it seems that brief therapies are, at least, equivalent to or, in some cases, superior to medication for the reduction of anxiety and depressive symptoms. Furthermore, it was not found any clinical differences between the combined treatment (brief therapies plus pharmacological intervention) and brief therapies applied by themselves, which might mean that psychotropic drugs could be unnecessary in most cases. The second study was a RCT with parallel design of three groups to compare the effectiveness of brief transdiagnostic therapy in both individual and group formats and pharmacological interventions for 102 patients with non-severe generalized anxiety disorder (GAD), mayor depressive disorder (MDD), panic disorder (PD) and/or somatoform disorder. Individual psychotherapy was developed in Specialized Care while group psychotherapy and treatment as usual was developed in PC. These psychological interventions were an adaptation of the Unified Protocol. The study followed the recommendations for intervention trials proposed in the SPIRIT (Standard Protocol Item: Recommendations for Interventional Trials) statement and the rules for the communication of the trials proposed in the CONSORT (Consolidated Standards of Reporting Trials) statement. Results showed that brief psychotherapies were more effective than medication for the reduction of EDs symptoms and diagnoses with moderate/high effect sizes. In addition, no clinical differences were found between the individual and group format. The third study aimed to determine the relation between three cognitive factors (rumination, worry, and metacognition) with the presence of GAD, PD or/and MDD symptoms from a sample of 116 individuals that consulted for the first time in PC services. Results pointed, on the one hand, that each ED had a closer link with a particular cognitive process and, on the other hand, that mixed EDs were associated with the three cognitive factors analyzed. These finding were discussed to give some recommendations to design efficient psychological treatments in terms of time and resources used. For instance, for “pure” disorders, targeting a concrete cognitive process might be the optimal therapeutic option. Nevertheless, due to the high comorbidity among EDs, the transdiagnostic treatment approach should be also considered. The fourth study was another RCT develop in PC with the objective to test one more time the effectiveness of a brief group transdiagnostic therapy for EDs compared with pharmacological interventions. Besides, two emotional regulation strategies and several cognitive factors were studied as predictors of the clinical changes. As before, this trial followed the SPIRIT and CONSORT statements. A total of 105 patients were randomized to one of the two possible interventions that were provided in PC centers. Results indicated that brief group transdiagnostic psychotherapy was more effective than medication in reducing all EDs symptoms with moderate/high effect sizes. Besides, it was found that changes in rumination, worry and metacognition could predict the improvement of MDD, GAD and PD, respectively and that these variables acted as predictors of the therapeutic change. For their part, cognitive reappraisal seemed to be linked to the improvement of a wide range of disorders, while expressive suppression could be particularly important when treating somatoform disorder. In conclusion, it seems that there is enough data to support the idea that brief and transdiagnostic psychotherapies are more effective than current interventions for the treatment of a wide range of EDs and that they could be spread within PC and Specialized Care. Although the best way of introducing these therapies is something that needs to be studied in the future, it is quite clear that they would improve people’s mental health in a more efficiently manner, since they would contribute to reduce waitlists and public costs. For that reason, governments and health managers should consider this scientific evidence and begin a health systems reform to ensure a quick and effective access to psychological therapies.