Interventions of computerized psychotherapies for depression in Primary Care in Spain

236 Re iew Ac as Esp Psiquia 2019;47(6):236-46 Albe o Ba celó-Sole 1 Rosa M. Baños2,3 Yolanda López-Del-Hoyo4 Fe mín Mayo al5,6 Ma galida Gili7 Azucena Ga cía-Palacios3,8 Ja ie Ga cía-Campayo1,4,9 C is ina Bo ella3,8 1 Ins i u o de In es igación Sani a ia A agón (IIS A agón), Za agoza, España 2 Uni e sidad de Valencia, Valencia, España 3 CIBER Fisiopa ología Obesidad y Nu ición (CIBERObn), Ins i u o Salud Ca los III, Mad id, España 4 Uni e sidad de Za agoza, Za agoza, España 5 Hospi al Regional Uni e si a io de Málaga, Málaga, España 6 Ins i u o de In es igación Médica de Málaga (IBIMA), Málaga, España 7 IUNICS-IDISBA, Uni e si a de les Illes Balea s, Palma, España 8 Uni e si a Jaume I, Cas ellón, España 9 Hospi al Uni e si a io Miguel Se e , Za agoza, España In e en ions o compu e ized psycho he apies o dep ession in P ima y Ca e in Spain Cu en ly, dep ession is a global heal h p oblem ecog- nized by he WHO. The p e alence o his pa hology in P i- ma y Ca e is es ima ed a 19.5% wo ldwide, and 20.2% in Spain. In addi ion, he cu en in e en ion policies and p o ocols in ol e signi ican cos s, bo h pe sonal and eco- nomic, o people su e ing om his diso de , as well as o socie y in gene al. On he o he hand, he elapse a es a e pha macological in e en ions ha a e cu en ly ap- plied and he lack o e ec i e specialized a en ion in men al heal h se ices e lec he need o de elop new he apeu ic s a egies ha a e mo e accessible and p o i - able. The e o e, one o he p oposals ha a e being in es- iga ed in di e en pa s o he wo ld is he design and e alua ion o he apeu ic p o ocols applied h ough In o - ma ion and Communica ion Technologies, especially h ough he In e ne and compu e p og ams. The objec- i e o his wo k was o p esen he cu en si ua ion in Spain ega ding he use o hese in e en ions o he ea men o dep ession in P ima y Ca e. The main conclu- sion is ha al hough he e is scien i ic e idence on he e ec i eness o hese p og ams, he e a e s ill impo an ba ie s ha hinde hei applica ion in he public sys em, and also he need o de elop implemen a ion s udies ha acili a e he ansi ion om esea ch o clinical p ac ice..* Keywo ds: In e ne -based in e en ion, Dep ession, P ima y Ca e, Compu e ized he apy, Online psycho he apy Ac as Esp Psiquia 2019;47(6):236-46 Co espondence: Yolanda López-Del-Hoyo Depa amen o de Psicología y Sociología Uni e sidad de Za agoza Za agoza, Spain E-mail: [email p o ec ed] In e enciones de psico e apia po o denado pa a la dep esión en A ención P ima ia en España La dep esión es, desde hace ya unos años, un p oble- ma de salud pública a ni el mundial econocido po la OMS. La p e alencia ac ual de es a pa ología, en los se icios de A ención P ima ia, se es ima en 19,5% a ni el mundial y en 20,2% en España. Además, las polí icas y p o ocolos de in e ención ac uales es án suponiendo unos impo an es cos es, an o pe sonales como económicos, pa a las pe sonas que padecen es e as o no, así como pa a la sociedad en ge- ne al. Po o o lado, los índices de ecaídas as las in e en- ciones a macológicas que se aplican ac ualmen e y la al a de una a ención especializada e icaz en los se icios de salud men al, ponen de elie e la necesidad de desa olla nue as es a egias e apéu icas más accesibles y cos e-e ec i as. En es a línea, una de las p opues as que se es án in es igando en di e en es pa es del mundo es el diseño y e aluación de p o ocolos e apéu icos aplicados a a és de las Tecno- logías de la In o mación y la Comunicación, especialmen e, a a és de in e ne y de p og amas de o denado . Po ello, el obje i o de es e abajo es p esen a la si uación ac ual de la a ención en España espec o a la u ilización de es as in e enciones pa a el a amien o de la dep esión en A en- ción P ima ia. La conclusión p incipal es que, aunque exis e e idencia cien í ica sob e la e icacia de es os p og amas, o- da ía exis en ba e as impo an es que di icul an su implan- ación en el sis ema público, y, po o o lado, la necesidad de desa olla es udios de implemen ación que acili en la ansición de la in es igación a la p ác ica clínica Palab as cla e: In e ención basada en in e ne , Dep esión, A ención P ima ia, Te apia compu a izada, Psico e apia online 237 Ac as Esp Psiquia 2019;47(6):236-46 In e en ions o compu e ized psycho he apies o dep ession in P ima y Ca e in SpainAlbe o Ba celó-Sole , e al. INTRODUCTION The p e alence o men al diso de s and speci ically emo ional diso de s is a ma e o in e es in ecen yea s due o i s implica ions bo h o people who su e om i and o he socie y in gene al. Dep ession is one o he mos common heal h p oblems wo ldwide. In 2004, he Wo ld Heal h O ganiza ion (WHO) es ima ed ha 151.2 million people su e ed om disabili y as a esul o his diso de , o which 22.2 million li ed in Eu ope, and s a ed ha in 2030 he dep ession will be he mos disabling disease in he whole wo ld1. Cu en ly, WHO es ima es ha 320 million people wo ldwide su e om dep ession, 44 million in Eu- ope and 2.4 million in Spain, and i is he hi d cause o yea s li ed wi h disabili ies in 20171. On he o he hand, se - e al epidemiological s udies ha e concluded ha i is he men al diso de ha has he g ea es impac on people’s heal h2-6. In P ima y Ca e (PC), a ecen me a-analysis concluded ha he gene al p e alence o dep ession is 19.5%7, while in Eu ope i is es ima ed o be 12.2%8. Speci ically in Spain, he p e alence h oughou li e is 10.6% and he annual is 4.0%, being below he a e age Eu opean le els9; and app oxima e- ly 30% o people ea ed in PC ha e su e ed an episode o dep ession10, wi h a gene al p e alence o 20.2%11. I is known ha dep ession en ails signi ican pe sonal and economic cos s o he indi idual and socie y. The e i- dence shows ha i is associa ed wi h a ious ch onic dis- eases such as cance , diabe es and ch onic pain, a ec ing quali y o li e, p oduc i e capaci y and economic in- come5,12,13. Rega ding he socio-heal h impac , i is he mos expensi e disease o Eu ope, assuming 33% o he esou c- es alloca ed o men al heal h, and 1% (118 billion eu os) o i s economy. Speci ically in Spain, he cos s o emo ional dis u bances in 2010 we e 10,763 million eu os14. These e- sul s a e consis en wi h hose ound in o he s udies con- duc ed on PC, s a ing ha i is a public heal h p oblem in Spain, in Eu ope and in he wo ld6,15. The e a e cu en ly e idence-based ea men s o de- p ession.16 In ac , i can be ea ed e ec i ely wi h pha ma- cological in e en ions, psycho he apies, o a combina ion o bo h17,18. These ea men s a e conside ed well es ablished ea men s19-22, and a e ecommended by he Ins i u e o Ex- cellence o Heal h and Ca e o he Uni ed Kingdom (NICE)23. F om he psychological app oach, Cogni i e Beha io al T ea men s (CBT) a e he ones ha ha e he mos empi ical suppo o he ea men o mul iple men al diso de s, and mo e speci ically o dep ession19,20,24. On he o he hand, SS- RIs a e he an idep essan s wi h g ea e e idence and be e isk/bene i balance o pa ien s, and he e o e he i s choice25. Howe e , al hough he combina ion o bo h s a egies has been p o en o be mo e e ec i e han indi idual appli- ca ion26, he e is a endency o pha macological p esc ip ion as he only in e en ion in PC, despi e he popula ion’s p e - e ence o psychological in e en ions, and he high a e o elapse a e d ug ea men 27-29. In addi ion, many people do no seek help among o he easons o ea o s igma i- za ion. Fu he mo e, e en in well-endowed heal h ca e sys- ems, i is di icul o ga he enough quali ied he apis s o o e psychological in e en ions30-32, and as a consequence, a signi ican numbe o people wi h dep ession do no e- cei e ea men 33,34. In Spain, a epo by he Spanish Agency o Medicines and Heal h P oduc s es ima ed ha he consump ion o an- idep essan s ipled be ween 2000 and 2013, and ha in many cases people a e medica ed who a e simply in a g ie - ing p ocess o su e om s ess ch onic35. Al hough his is no consis en wi h he ecommenda ions, he e a e easons ha can explain his si ua ion. One o he di icul ies o he in eg a ion o psycho he apy in PC is he s anda d du a ion o hese p og ams (be ween 10-12 weeks). O he di icul a e he cu en policies ega ding psychological ca e, limi ed esou ces, and he lack o men al heal h p o essionals in he con ex o PC25. I can be concluded ha men al heal h esou ces dedi- ca ed o dep ession a e no adequa e in e ms o accessibil- i y and quali y36, since less han 50% o people wi h dep es- sion a e ea ed by a heal h p o essional, and only a ou h pa y ecei es he app op ia e ea men due o he cos s and demands o ace- o- ace ea men s, he ime equi ed o i s applica ion o he lack o ained he apis s37. As a esul o he di icul ies in in eg a ing psychologi- cal in e en ions wi hin he PC, i is necessa y o apply s a - egies ha acili a e his p ocess. P es igious au ho s in his ield p opose o de elop mo e e icien in e en ions o e- duce he disease bu den o dep ession and allow hei access o he popula ion ega dless o socioeconomic s a us16,38. One o he al e na i es unde in es iga ion is he use o low in ensi y in e en ions23 as: a) b ie psycho he apies be- ween 6-10 sessions om he CBT39, p oblem sol ing, in e - pe sonal he apy40, b) biblio he apy41, c) sel -help p og ams42 y d) compu e -assis ed psycho he apy p og ams43. This, o- ge he wi h he s epped ea men model, p oposed by na- ional and in e na ional guides, a e sugges ed as he mos easible al e na i es o be in oduced in he heal h sys- em23,44,45. The objec i e is o ea as soon as possible, a la ge p opo ion o pa ien s wi h he apies ha a e known o be e ec i e, educing di ec and indi ec cos s, as well as he impac on heal h. O he ad an ages o he s epped ea - men is ha i is simple han o mal psycho he apies and can be p o ided by heal h p o essionals besides men al heal h expe s. Howe e , e en wi h he possibili y o using In e en ions o compu e ized psycho he apies o dep ession in P ima y Ca e in SpainAlbe o Ba celó-Sole , e al. 238 Ac as Esp Psiquia 2019;47(6):236-46 hese in e en ions, indi idual psycho he apy, he dominan model in he p o ision o psychological se ices, is unlikely o sa is y hese needs36,46. We will he e o e ha e o hink abou o he possibili ies. In o ma ion and Communica ion Technologies (ICTs), especially he use o he In e ne o ap- ply psychological ea men p og ams, ha e p o en o be a powe ul ehicle o hei e ec i e deploymen in men al heal h se ices31,47. APPLICATION OF ICTs: INTERNET-BASED TREATMENTS In ecen yea s, impo an con ibu ions ha e been made ega ding he use o he In e ne o apply psycholog- ical ea men s in he ield o emo ional diso de s. These a e e idence-based ea men p o ocols ha a e manualized and adap ed o be applied o e he In e ne using mul ime- dia ma e ials ( ideos, s ips, ex s ...). The wo k ca ied ou by di e en g oups a ound he wo ld s ands ou , being he i s s udies by Isaac Ma ks and Judi h P oud oo in he Uni ed Kingdom, who de eloped he Fea Figh e and Bea ing he Blues ea men p og ams, included in he NICE Guidelines o he ea men o dep ession and panic diso de . The da a indica e ha hese in e en ions a e a p omis- ing al e na i e o cu en s a egies48, and nume ous me- a-analysis ha e demons a ed he clinical e icacy and e - ec i eness o In e ne -based ea men s o dep ession.49,50 In addi ion, e idence indica es ha hey a e as e ec i e as adi ional ea men s42,51. I has been p o en ha hey a e a easible solu ion and a use ul s a egy o p omo e e i- dence-based psycho he apies, sol e accessibili y p oblems and acili a e he implemen a ion o in e en ions52. The li - e a u e indica es ha hese psychological in e en ions ap- plied h ough he In e ne can help sol e impo an men al heal h p oblems and o e come access ba ie s o ea men s such as geog aphical limi a ions since hey can each popu- la ions o pa ien s who do no a end he apy due o dis- ance o he economic cos , o educe he s igma associa ed wi h ecei ing psycho he apy36,53,54. In his way, a ecen me- a-analysis based on indi idual da a om 3,876 pa ien s con i ms ha sel -guided psychological ea men s applied by he In e ne a e e ec i e in ea ing dep essi e symp- oms, p o iding subs an ial e idence o clinical and poli i- cal decision making, since he da a indica e ha such s a - egies can be conside ed as an e idence-based app oach o choice o he ea men o dep ession55. Wi hin he amewo k o he Eu opean OPTIMI p ojec (“Online P edic i e Tools o In e en ion in Men al Illness”), a manualized ea men p o ocol called Smiling is Fun was de eloped, which was also adap ed o be applied h ough he In e ne 56,57. This p og am combines e ec i e psycholog- ical p ocedu es o s ess managemen and dep essi e symp- oma ology wi h s a egies o p omo e emo ional egula- ion, coping abili y and esilience. I s objec i e is o he pe son o lea n di e en psychological echniques such as adap i e new ways o coping o deal wi h clinical symp oms, as well as o deal wi h e e yday p oblems. The o iginal p og am consis ed o 8 modules ha in- cludes classic componen s o CBT, such as psychoeduca ion, mo i a ion o change, cogni i e he apy and elapse p e- en ion58. In addi ion, i inco po a es a beha io al ac i a ion componen 59 and a posi i e psychology componen ha o - e s a egies o p omo e and imp o e posi i e mood60. Sub- sequen ly, wo addi ional modules we e de eloped, one o- cused on sleep hygiene s a egies and ano he on medica ion managemen . Table 1 shows he objec i es o all module. Each modules del es in o an impo an aspec o imp o e coping capaci y and includes exe cises designed o lea n se e al psychological echniques. The p o ocol was adap ed o he web sys em becoming an in e ac i e, sel -applied in e en ion ool, and o be ap- plied h ough he In e ne . In i s de elopmen , special a en- ion was paid o he easiness o use, wi h a minimalis design ha emphasises he con en o e he es o he elemen s and a linea na iga ion, which allows use s wi h less expe i- ence wi h ICTs o know a all imes whe e hey a e and how o con inue ad anced. The p og am begins wi h he “Home” module whe e i is explained wha i is, wha he objec i e is, who can bene i om i and who a e he p o essionals behind he de elop- men o he p og am (See Figu e 1). The s uc u e o he modules ollows he ollowing scheme: ques ions ela ed o he p e ious module, he ex- plana ion o he con en s o he module, he pe o mance o he exe cises and, inally, he sel - es ques ions o check i he use has unde s ood wha has been explained. I use does no answe a ques ion, he p og am immedia ely p o- ides he co ec eedback wi h a simple explana ion. Subse- quen ly, he asks ha ha e o be done o p ac ice wha has been wo ked on in he module a e indica ed, and i s pe o - mance is ecommended. In addi ion o he 10 ea men modules, ools a e o e ed ha help he use h oughou he en i e p ocess: --Ac i i y Dia y: designed so ha he pe son pays a en- ion o he ac i i ies he/she pe o ms daily, wha he/she spends ime on and how his in luences mood, coping abili y and s ess le el. --Schedule: i p o ides in o ma ion o he pe son abou his/he p og ess h oughou he p og am. I le s use know whe e he/she is, wha he/she need o inish and gi es his/he eedback on he asks he/she s ill has pending and hose he/she has al eady done. 239 Ac as Esp Psiquia 2019;47(6):236-46 In e en ions o compu e ized psycho he apies o dep ession in P ima y Ca e in SpainAlbe o Ba celó-Sole , e al. Table 1 Objec i es o he p og am “Smiling is Fun” Modules Main Objec i es 1. “Medica ion managemen ” The guidelines o he p ope use o he medica ion a e p esen ed (i p esc ibed). 2. “Sleep hygiene” Guidelines o adop ing heal hy sleep habi s a e p esen ed. 3. “Mo i a ion o change” The objec i e o his module is o ge he use o analyze i hey eally wan o change and o conside he bene i s and cos s o he change. 4. “Unde s anding emo ional p oblems” In o ma ion is p o ided so ha he pe son can unde s and emo ional p oblems. 5. “Lea ning o mo e on” The impo ance o “ge ing s a ed” is augh o adop an adequa e le el o ac i i y and in ol emen wi h li e. 6. “Lea ning o be lexible” The pe son lea ns he impo ance o making hei hinking mo e lexible and in e p e ing si ua ions 7. “Lea ning o enjoy” The impo ance o posi i e emo ions and being in con ac wi h o he people is emphasised. 8. “Lea ning o li e” The pe son lea ns he di e ence be ween posi i e expe iences, which in ol e momen s o momen a y pleasu e, and he achie emen o psychological well- being and helps iden i y hei own s eng hs. 9. “Li ing and lea ning” Li e is a p ocess o cons an lea ning and all expe iences a e use ul and i is impo an o “lea n o lea n” om hem. The pe son is augh o iden i y and de ec momen s o well-being. 10. “F om now on, wha else?” E e y hing explained abo e is wo ked on in he elapse p e en ion componen . Figu e 1 Module “Home” --How am I: i o e s g aphical eedback on he e olu- ion h oughou he p og am, as well as he le el o ac- i i y, emo ional dis ess and he in ensi y o posi i e and nega i e emo ionali y. Smiling is Fun was ini ially es ed in a communi y sam- ple unde s ess56,57 ob aining good esul s. Likewise, ano he s udy was ca ied ou in a communi y sample wi h dep es- si e symp oma ology61 wi h also posi i e esul s . Based on hese s udies, i was decided o use his p og am o es i s e ec i eness in PC a se e al Spanish egions. THE USE OF ICTS FOR THE TREATMENT OF DEPRESSION IN PC IN SPAIN Despi e he e idence showing he e ec i eness o ICT- based in e en ions, i has no been es ed in he PC con ex in Spain un il a ew yea s ago. Thus, wi h he objec i e o compa ing he e ec i eness o low in ensi y p og ams based on he use o he In e ne e sus he usual ea men in PC o majo dep ession, a andomized con olled clinical ial (RCT) was designed using he p og am Smiling is Fun: The s udy is an RCT consis ing o h ee g oups, each as- socia ed wi h di e en ea men condi ions. Pa ien s e- cei ed he usual imp o ed ea men (TAU), o he p og am Smiling is Fun wi h o wi hou suppo om a he apis ; he In e en ions o compu e ized psycho he apies o dep ession in P ima y Ca e in SpainAlbe o Ba celó-Sole , e al. 240 Ac as Esp Psiquia 2019;47(6):236-46 suppo implied ha he pa ien could eques ad ice om a p o essional up o a maximum o h ee con ac s by mail du ing he pe iod o ea men . The pa icipan s we e selec ed by amily doc o s in PC cen e s in Andalusia, A agon, Balea ic Islands and Valencia. They we e selec ed h ough he use o case sea ch ques ion- nai es by he gene al p ac i ione and subsequen ly e alua - ed by an independen in es iga o using he In e na ional Neu opsychia ic In e iew (MINI). Pa ien s be ween he ages o 18 and 65 wi h a diagnosis o Majo Dep essi e Dis- o de acco ding o he DSM-5 and ICD-10 guidelines, whose le el o se e i y was mild o mode a e acco ding o he Spanish Beck Dep ession In en o y-II, we e conside ed ade- qua e o he s udy. Those pa ien s who had ecei ed psy- chological ea men du ing he p e ious yea we e no in- cluded, no hose who me c i e ia o any o he Axis I diso de and pa ien s wi h se e e dep ession. The pa ici- pan s we e eassessed a e comple ing he p og am as well as a 3, 6 and 15 mon hs o pos -in e en ion ollow-up. In he pos - ea men assessmen he e we e no signi - ican di e ences in he e ec i eness o he h ee ypes o ea men in educing dep essi e symp oma ology. Howe - e , he wo condi ions ha included he p og am Smiling is Fun p o ed o be mo e e ec i e han he TAU a bo h 6 and 15 mon hs. The e we e no di e ences ega ding he e ec- i eness be ween he wo expe imen al g oups. Rega ding he esul s ob ained in he a iables “men al heal h” e alua ed wi h he Sho Fo m Heal h Su ey (SF- 12) and “quali y o li e” wi h he Eu oQol (EQ-5D), he e- sul s ollowed a simila pa e n. Rega ding he quali y o men al heal h, he esul s we e simila o he h ee ypes o in e en ion a 3 mon hs ollow-up. Howe e , bo h In e ne in e en ion p og ams p o ed o be mo e e ec i e han TAU a 6 and 15 mon hs. Simila ly, he h ee ypes o in e en- ion did no di e in imp o ing he quali y o li e a 3 mon hs ollow-up. Howe e , he In e ne in e en ion p o- g am wi h he apeu ic suppo did p o e o be mo e e ec- i e a 6 and 15 mon hs. The economic analysis o he in e en ion was ca ied ou om he pe spec i e o he paye (di ec cos s o medi- ca ion and use o heal h se ices) and social (indi ec ex- penses o loss o wo king hou s and sick lea e) compa ing he TAU g oup. The ime ame co e s he 12-mon h du a- ion o he s udy and cos -e ec i eness (CE) and cos -ben- e i (CB) analyzes we e pe o med. The CE analysis compa es he expenses and heal h ou comes o bo h in e en ions. Thei esul s a e exp essed in e ms o he inc ease in cos e ec i eness o one in e en ion wi h espec o he o he (ICER) pe heal h uni (in his case educ ion o dep essi e symp oma ology). ICER= Cos ea men in e en ion g oup Cos s ea men con ol g oup E ec i eness ea men in e en ion g oup E ec i eness ea men con ol g oup - - The Cos -u ili y (CU) analysis es ima es he p o i abili y o he in e en ions and uses s anda dized heal h uni s as a e e ence, such as he yea s o li e adjus ed o quali y o li e (QUALYS) o yea s o li e adjus ed o disabili y (DALYS). The esul s a e exp essed as he inc ease o (ICU), which is he di e ence in cos s necessa y o achie e a uni o measu e- men o hese dimensions o bo h in e en ions. ICUR= Cos ea men in e en ion g oup Cos s ea men con ol g oup QUALY won in in e en ion g oup QUALY won in con ol g oup - - The esul s o he s udy showed signi ican di e ences in a o o he in e en ion g oup65. The ne cos s (di ec + indi ec expenses) o he TAU g oup was 1,716€ pe pa ien while hose who ollowed online ea men had an a e age cos o 1,532€ pe pa ien , which means a ne sa ing o 184€ pe ea ed pa ien . On he o he hand, he analysis o economic esul s by in en ion o ea showed an ICER o - 169.50€ and an ICUR o - 496€ a o able o he g oup ea ed by in e ne . The e o e, he esul s o he economic analysis showed ha he In e ne ea men o mild and mode a e dep essi e symp oms in PC is cos e ec i e and e icien . Based on he expe ience de eloped du ing he i s RCT ca ied ou in Spain and he e idence published by esea ch g oups om o he coun ies on he e alua ion o he e ec- i eness o sho and low in ensi y psychological in e en- ion p og ams applied h ough ICTs, we wo ked on he de- sign o a mul icen e RCT, in which h ee psychological in e en ions we e adap ed o a sho o ma o be applied h ough a websi e. The inal objec i e was o design a he - apeu ic s a egy ha acili a es access o psychological ea men by PC pa ien s. The h ee adap ed in e en ions we e: a) li es yle psy- choeduca ion, b) posi i e a ec p omo ion, and c) mind ul- ness. Each p og am consis ed o 4 online modules wi h mul- imedia ma e ial and wi h an es ima ed du a ion o 60 minu es. The p og ams we e designed o be ca ied ou in a pe iod o 4-8 weeks, al hough i would depend on he pace o he pa icipan . Tables 2, 3 and 4 p esen he objec i es o all modules, and Figu e 2 shows he home page o he p o- g am whe e i is speci ied who can bene i om i and mo e ele an in o ma ion p io o he s a o he in e en ion. 241 Ac as Esp Psiquia 2019;47(6):236-46 In e en ions o compu e ized psycho he apies o dep ession in P ima y Ca e in SpainAlbe o Ba celó-Sole , e al. The inclusion / exclusion c i e ia, andomiza ion ec ui - men and ollow-up ollowed he same line in he p e ious RCT. Howe e , he se e i y o dep essi e symp oma ology was assessed wi h he PHQ-9 scale, and o he scales we e added such as he FFMQ o assess he le el o mind ulness, he PHI o analyzing subjec i e well-being, and he CSRI ha includes in o ma ion on he use o heal h se ices as well as he economic impac ha pa ien s expe ience. Pa - icipan s we e assessed be o e beginning he in e en ion, a he end, and wo ollow-ups a 6 and 12 mon hs pos - ea men . Al hough he esul s o his p ojec a e no ye inished, hey a e expec ed o p o ide e idence on he e alua ion o h ee sho in e en ions o low in ensi y and applied h ough ICTs in he imp o emen o dep essi e symp om- a ology as well as on he easibili y o he implemen a ion o his ype o he apies in PC66. DISCUSSION The objec i e o his pape has been o p esen he cu - en si ua ion ega ding he use o In e ne psycho he apy p og ams o he ea men o dep ession in PC in Spain. The i s conclusion o emphasise is ha i is an incipien ield, bu has al eady gi en posi i e esul s. Da a om bo h clini- cal and economic pe spec i e suppo he use o hese s a - egies o gi e be e a en ion o ci izens. Howe e , jus showing e icacy is no enough, a his ime i is necessa y o ca y ou implemen a ion s udies o design and es he pos- sible s a egies ha allow he inco po a ion o hese p o- Table 2 Obje i os de los módulos del p og ama de psicoeducación en es ilo de ida Modules Main Objec i es 1. “Beginning o a li es yle change” Know he ela ionship be ween a heal hy li es yle and physical and men al well-being. Iden i y heal hy and isky beha io s as well as obs acles and excuses ha make i di icul o adop an adequa e li es yle. 2. “Physical ac i i y. Lea ning o mo e” Emphasise he impo ance o physical ac i i y and i s in luence on mood, and lea n he keys o inc ease mo i a ion and s a being mo e ac i e. 3. “Die . Lea ning o ea ” Know he ela ionship o a heal hy and balanced die wi h emo ional heal h. Iden i y he ba ie s ha make i di icul o adop and main ain an adequa e die . 4. “Sleep. The impo ance o good sleep” P o ide gene al in o ma ion abou sleep and i s al e a ions, lea n s a egies o handle sleep- ela ed p oblems and sleep be e . Table 3 Objec i es o he p omo ion o posi i e a ec modules Modules Main Objec i es 1. “Lea ning o li e” Emphasise he impo ance o he ole o meaning ul ac i i ies in mood and well-being, as well as seek he suppo o o he people o ca y hem ou . 2. “Lea ning o enjoy” Analyze he impo ance o posi i e emo ions and he alue o he “li le hings” o e e yday li e, and he impo ance o knowing how o li e and enjoy in he p esen momen . 3. “Accep ing o li e” De elop an adap i e ela ionship and sa is ac ion wi h pas expe iences. Build us owa ds he u u e and lea n o handle e en s ha dis up and dis u b momen s o well-being. 4. “Li ing and lea ning” The use lea ns s a egies o inc ease esilience and psychological well-being. Iden i y he po en iali ies linked o alues and de elop an ac ion plan o achie e a meaning ul li e. In e en ions o compu e ized psycho he apies o dep ession in P ima y Ca e in SpainAlbe o Ba celó-Sole , e al. 242 Ac as Esp Psiquia 2019;47(6):236-46 Table 4 Objec i es o he p omo ion o posi i e a ec modules Modules Main Objec i es 1. “Ge ing o know mind ulness” Lea n wha is and wha is no mind ulness. Know he p oblem o ina en ion and know he bene i s and basic ecommenda ions o he p ac ice. 2. “Es ablishing o mal and in o mal p ac ices” Know he di e ence be ween o mal and in o mal p ac ice, and he main p ac ices (mind ulness in b ea hing and h ee minu es p ac ice). 3. “Though managemen , body scan p ac ice and alues” Lea n o manage hough s. Di e en ia e be ween p ima y and seconda y su e ing. Unde s and he impo ance o alues in li e and know he p ac ice o he body scanne . 4. “Sel -compassion. In eg a ing mind ulness in e e yday li e” Lea n main ain he p ac ice in daily li e. Expose and do he p ac ice o mind ulness walking. he p ac ice o compassion, and how o in oduce and Figu e 2 Homepage g ams in ou ine ca e o he ea men o dep ession and o he p oblems o men al heal h in PC. These p og ams ha e di e en ad an ages o e he usual ea men ha should be conside ed. Eells and collab- o a o s on he one hand, and Cuijpe s and Ripe on he o h- e , conduc ed wo e iews64,65 on he use o hese p og ams o he ea men o dep ession and hei conclusions indi- ca e ha hey a e a cheape and mo e e icien op ion han he usual ea men since once designed and adap ed o a websi e o compu e p og am i is less expensi e o admin- is e o a la ge numbe o pa ien s. I acili a es access o he in e en ion o any pe son who has in e ne access, be- ing a ailable whene e a pe son needs i , sa ing he geo- g aphical ba ie s and wai ing lis s o heal h se ices. They allow o s anda dize he ea men componen s so ha hey a e be e o ganized, bo h he heo e ical con en s and he p ac ical exe cises o each pa ien as well as he possibili y o adap ing hem o each pa icula case. These p og ams also a o be e managemen o he in o ma ion ob ained om he pa ien , allow con inuous moni o ing o hei p og ess and p o ide da a o heal h se ices and hose e- sponsible o heal h policies abou in e en ions ha wo k (o do no ), which is essen ial in making ac ion decisions. And inally, adhe ence o ea men could be signi ican ly inc eased aking in o accoun aspec s such as s igma o en associa ed wi h su e ing om a men al illness, since some pa ien s p e e he apy applied h ough an In e ne a he han a ending an expensi e psycho he apeu ic session o ace wi h a he apis . Howe e , despi e hese ad an ages, i is impo an o conside he possible limi a ions o hese in e en ions. The i s is ha hey do no ha e he human ac o , and he e- o e, he empa hic aspec ha is p esen in he adi ional he apies can be educed causing some pa ien s o be eluc- an o his o ma . Ano he limi a ion is he di icul y in designing a ac i e and use ul p og ams o all pa ien s and ha a e a leas as e ec i e as s anda d he apy. Ano he issue is he di icul y in ying o ans e hem o clinical p ac ice; some imes, p og ams ha ha e shown hei e ec- i eness in he expe imen al phase ha e ob ained no so posi i e esul s in hei applica ion in PC. The e o e, imple- men a ion s udies a e essen ial. I has also been obse ed ha he a i ude o p o essionals is some imes mo e nega- i e compa ed o ha o pa ien s ega ding his ype o in- e en ions. Finally, i is impo an o conside ha many ques ions s ill emain unanswe ed, o example, he mecha- nisms o ac ion o his he apeu ic o ma a e unknown, o which speci ic pa ien p o iles is mo e bene icial, o wha is he bes way o adap hem o di e en cul u al con ex s. 243 Ac as Esp Psiquia 2019;47(6):236-46 In e en ions o compu e ized psycho he apies o dep ession in P ima y Ca e in SpainAlbe o Ba celó-Sole , e al. The e is a lo o esea ch o be done o achie e an e ec- i e and e icien applica ion o hese p og ams in heal h se ices, and in his way hey can be use ul o people. In his ega d, se e al lines o wo k a e being opened ha will be key o achie ing no only he objec i e o implemen ing hese in e en ions on PC bu also going beyond wha adi- ional models allow o apply psychological ea men s. Fo ins ance, he Ecological Momen a y Assessmen (EMAs) and he Ecological Momen a y In e en ion (EMIs) a e s a egies ha allow o ob ain di ec in o ma ion in eal ime o he pe son’s expe iences while in hei na u al en i onmen as well as o in e ene clinically wi h g ea e ecological alidi- y. These me hodologies a e possible hanks o he use o sma phones and senso s in eg a ed in hese de ices, po a- ble biosenso s and he applica ion o pe sonalized e alua- ion epo s. Mille ’s wo k s ands ou 66 poin ing ou he e - olu ion ha hese de elopmen s will b ing o psychology. A he momen , se e al e iews ha e shown ha e en being new s a egies and wi h impo an possibili ies o imp o e- men he e a e impo an bene i s in hei applica ion in he case o dep ession by allowing he con inuous e alua ion o he pa ien ’s mood in he na u al con ex hus educing bias as a eminde , o ca y ou indi idualized in e en ions o each pe son, as well as he con inuous e iew o he e ec o he ea men . Undoub edly, bo h EMAs and EMIs a e be- coming inc easingly powe ul esou ces o ea men and p e en ion due o ad ances in echnological capaci y and sophis ica ion ega ding da a analysis67-70. This line o wo k is especially ele an o dep ession due o he cha ac e is- ics o his diso de , especially luc ua ions in symp oms o e ime; he e o e, he e is a need o c ea e new e alua- ion and in e en ion ools ha allow each indi idual o be se ed in he bes possible way, aking in o accoun hei pe sonal cha ac e is ics and con ex . In his ega d, he i s esea ch s udies o Spanish g oups a e being de eloped whe e di e en aspec s o hese me hodologies a e s udied in he psychia ic popula ion71-74. Ano he echnological ad ance ha is a ac ing he a en ion o esea che s is i ual eali y and augmen ed e- ali y. Al hough he e is s ill insu icien scien i ic e idence on he applica ion o hese ools in dep ession, he e a e con olled clinical ials and e iew and me a-analysis s ud- ies in which he e ec i eness and e ec i eness o i ual eali y in a popula ion wi h anxie y and / o emo ional p ob- lems75-78 in which i is concluded ha i is a p omising ool in imp o ing he ea men o his symp oma ology. Despi e he abo e, i is impo an o bea in mind ha he pa adigm shi p esen ed by hese echnological ad- ances applied o psycho he apy implies unp eceden ed o ms o pe son / machine in e ac ion ha can gene a e new dilemmas and e hical obs acles o achie e he ul ima e objec i e o any psychological in e en ion; al hough he da a indica e ha hese scien i ic inno a ions a e being well accep ed by pa ien s55,79 and he p og ams designed and ap- plied, bo h h ough he in e ne and i ual eali y, lack ad- e se e ec s80 showing hemsel es as p omising al e na i es o cu en he apeu ic s a egies. Exis andomized con olled s udies conduc ed in he PC se ing in Spain ha ha e success ully applied and es ed psychological ea men p o ocols applied h ough he In- e ne o dep ession. These s udies ha e p o en o be e ec i e and cos -e - ec i e compa ed o adi ional ea men . The e a e s ill impo an ba ie s o in eg a e hese new echnological and clinical ad ances in he public heal h sys- em and o his i is necessa y o ca y ou implemen a ion s udies. In addi ion o he In e ne -based ea men p og ams, he e a e o he echnologies such as i ual eali y, aug- men ed eali y o he use o senso s and sma phones, which ha e been de eloped in ecen yea s, which a e impo an o keep in mind since hey a e going o lead o impo an ad- ances in his ield. ACKNOWLEDGEMENTS Au ho s app ecia e he suppo p o ide by he A agon Ins i u e o Heal h Resea ch (IIS A agon), and he Ne wo k o P e en ion and Heal h P omo ion in P ima y Ca e (RD/16/0007/0005) g an om he Ins i u o de Salud Ca los III o he Spanish Minis y o Economy and Compe i i eness. COMPETING INTERESTS The au ho s decla e ha hey ha e no inancial o o he compe ing in e es s. REFERENCES 1. Wo ld Heal h O ganiza ion. The global bu den o disease 2004. Swi ze land; 2004. 2. Wi chen HU, Jacobi F, Rehm J, Gus a sson A, S ensson M, Jönsson B, e al. The size and bu den o men al diso de s and o he diso de s o he b ain in Eu ope 2010. Eu Neu opsychopha macol. 2011;21(9):655-79. 3. Paykel ES, B ugha T, F ye s T. Size and bu den o dep essi e diso de s in Eu ope. Eu Neu opsychopha macol. 2005;15:411-23. 4. Moussa i S, Cha e ji S, Ve des E, Tandon A, Pa el V, Us un B. Dep ession , ch onic diseases , and dec emen s in heal h: esul s om he Wo ld Heal h Su eys. Lance . 2007;370:851-8. 5. Kessle RC, B ome EJ. The Epidemiology o Dep ession Ac oss Cul u es. Annu Re Public Heal. 2013;119-38. 6. Ha o J, Ayuso-Ma eos J, Bi e I, Demo es-Maina d J, Leboye M, Lewis S, e al. ROAMER: oadmap o men al heal h esea ch in Eu ope. In J Me hods Psychia Res. 2014;24:1-14. In e en ions o compu e ized psycho he apies o dep ession in P ima y Ca e in SpainAlbe o Ba celó-Sole , e al. 244 Ac as Esp Psiquia 2019;47(6):236-46 7. Mi chell AJ, Vaze A, Rao S, In i R. Clinical diagnosis o dep ession in p ima y ca e : a me a-analysis. Lance . 2009;374(9690):609-19. 8. King M, Naza e h I, Le y G, Walke C, Mo is R, Weich S, e al. P e alence o common men al diso de s in gene al p ac ice a endees ac oss Eu ope. B J Psychia y. 2008;362-7. 9. Gabilondo A, Rojas- a e as S, Vilagu G, Ha o JM, Fe nández A, Pin o-meza A, e al. Epidemiology o majo dep essi e episode in a sou he n Eu opean coun y : Resul s om he ESEMeD-Spain p ojec . J A ec Diso d. 2010;120(1-3):76-85. 10. Se ano-Blanco A, Palao DJ, Luciano J V, Pin o-Meza A, Luján L, Fe nández A, e al. P e alence o men al diso de s in p ima y ca e: esul s om he diagnosis and ea men o men al diso de s in p ima y ca e s udy (DASMAP). Soc Psychia Epidemiol. 2010;(45):201-10. 11. Ho al EG, Royo JMV, Abad JMH, So iano IB, Blanca AJ, P a MA. P e alencia y de ección de los as o nos dep esi os en a ención p ima ia. A en P ima ia. 2002;29(6):329-35. 12. Simon GE, Chisholm D, T eglia M, Bushnell D, G oup TL. Cou se o Dep ession, Heal h Se ices Cos s, and Wo k P oduc i i y in an In e na ional P ima y Ca e S udy. Gen Hosp Psychia y. 2003;(Ap il):293-308. 13. Sco KM, B u ae s R, Tsang A, O mel J, Alonso J, Ange meye MC. Dep ession – anxie y ela ionships wi h ch onic physical condi ions : Resul s om he Wo ld Men al Heal h su eys. J A ec Diso d. 2007;103:113-20. 14. Pa és-Badell O, Ba baglia G, Je inic P, Gus a sson A, Sal ado - Ca ulla L, Alonso J. Cos o Diso de s o he B ain in Spain. PLoS One. 2014;9(8). 15. Fe a i AJ, Cha lson FJ, No man RE, Pa en SB, F eedman G, Mu ay CJL, e al. Bu den o Dep essi e Diso de s by Coun y , Sex , Age , and Yea : Findings om he Global Bu den o Disease S udy 2010. PLoS Med. 2013;10(11). 16. Na han P, Go man J. A Guide o T ea men s ha Wo k. 4 d ed. P ess OU, edi o . New Yo k; 2015. 17. Cuijpe s P, Reynolds C, Donde T, Li J, Ande sson G, Beekman A. Pe sonalized ea men o adul dep ession: medica ion, psycho he apy, o bo h? A sys ema ic e iew. Dep ess Anxie y. 2012;29(10):855-64. 18. Cuijpe s P, an S a en A, Ande sson G, an Oppen P. Psycho he apy o dep ession in adul s: A me a-analysis o compa a i e ou come s udies. Consul Clin Psychol. 2008; 76(6):909-22. 19. Hollon SD, Ponniah K. A e iew o empi ically suppo ed psychological he apies o mood diso de s in adul s. Dep ess Anxie y. 2010;932(May):891-932. 20. Cuijpe s P, S a en A Van, Wa me dam L. Beha io al ac i a ion ea men s o dep ession: A me a-analysis. Clin Psychol Re . 2007;27:318-26. 21. Linde K, Rücke G, Sig e man K, Jamil S, Meissne K, Schneide A. Compa a i e e ec i eness o psychological ea men s o dep essi e diso de s in p ima y ca e: ne wo k me a-analysis. BMC Fam P ac . 2015 Aug 19;16:103. 22. Zhang A, F anklin C, Jing S, Bo nheime LA, Hang A, Himle JA, e al. Jou nal o A ec i e Diso de s The e ec i eness o ou empi ically suppo ed psycho he apies o p ima y ca e dep ession and anxie y: A sys ema ic e iew and me a-analysis. J A ec Diso d. 2019;245(No embe 2018):1168-86. 23. Na ional Collabo a ing Cen e o Men al Heal h. Dep ession. The ea men and managemen o dep ession in adul s. London, England: The b i ish psychological socie y and he oyal college o psychia is s; 2010. 24. Ka yo aki E, Smi Y, Hold -Henningsen K, Huibe s M, Robays J, de Beu s D, e al. Combining pha maco he apy and psycho he apy o mono he apy o majo dep ession? A me a-analysis on he long- e m e ec s. J A ec Diso d. 2016;194:144-52. 25. G upo de abajo de la Guía Clínica sob e el Manejo de la Dep esión en el Adul o. Guía de P ác ica Clínica sob e el Manejo de la Dep esión en el Adul o. A alia- , edi o . Minis e io de Sanidad, Se icios e Igualdad. Agencia de E aluación de Tecnologías Sani a ias de Galicia (a alia- ); 2014. 26. Cuijpe s P. Combined Pha maco he apy and Psycho he apy in he T ea men o Mild o Mode a e Majo Dep ession? JAMA psychia y. 2015;2014-5. 27. McHugh R, Whi on S, Peckham A, Welge J, O o M. Pa ien P e e ence o Psychological s. Pha macological T ea men o Psychia ic Diso de s: A Me a-Analy ic Re iew. J Clin Psychia y. 2014;74(6):595-602. 28. Haan M De, Ph D, Dyck R Van, Ph D. Pa ien s’ p e e ences in he ea men o dep essi e diso de in p ima y ca e. Psychia y P im Ca e. 2004;26:184-9. 29. Gill D, Ha che S, Gill D, Ha che S. An idep essan s o dep ession in medical illness (Re iew). Coch ane Da abase Sys Re . 2010;(4). 30. Moh D, Ha S, Howa d I, Julian L, Vella L, Ca ledge C, e al. Ba ie s o psycho he apy among dep essed and nondep essed p ima y ca e pa ien s. Ann Beha Med. 2006;32(3):254-8. 31. Ti o N. In e ne -deli e ed psycho he apy o dep ession in adul s. Cu Opin Psychia y. 2011;24(1):18-23. 32. Ba ney L, G i i hs K, Ch is ensen H, Jo m A. Explo ing he na u e o s igma ising belie s abou dep ession and help- seeking: implica ions o educing s igma. BMC Public Heal h. 2009;9(1):61. 33. And ews G, Hende son S, Hall W. P e alence, como bidi y, disabili y and se ice u iliza ion: o e iew o he Aus alian Na ional Men al Heal h Su ey. B J Psychia y. 2001;178(2):145-53. 34. Spijke J, Bijl R, de G aa R, Nole W. Ca e u iliza ion and ou come o DSM-III-R majo dep ession in he gene al popula ion: esul s om he Ne he lands Men al Heal h Su ey and Incidence S udy (NEMESIS). Ac a Psychia Scand. 2001;104(1):19-2. 35. AEMPS. U ilización de medicamen os an idep esi os en España du an e el pe iodo 2000-2013. Mad id; 2015. A ailable om: h ps://www.aemps.gob.es/medicamen osU-soHumano/ obse a o io/docs/an idep esi os-2000-2013. pd . 36. Kazdin A, Blase S. Reboo ing psycho he apy esea ch and p ac ice o educe he bu den o men al illness. Pe spec Psychol Sci. 2011;6(1):21-37. 37. And ews G, Issakidis C, Sande son K, Co y J, Lapsley H. U ilising su ey da a o in o m public policy: compa ison o he cos - e ec i eness o ea men o en men al diso de s. B J Psychia y. 2004;184(6):526-33. 38. Kazdin A. Technology-Based In e en ions and Reducing he Bu dens o Men al Illness: Pe spec i es and Commen s on he Special Se ies. Cogn Beha P ac . 2015;22:359-66. 39. San o F, Axelsson E, Ös L, Hedman-Lage lö M, Fus J, Hedman-Lage lö E. Cogni i e beha iou he apy o dep ession in p ima y ca e: sys ema ic e iew and me a-analysis. Psychol Med. 2019;28:1-9. 40. Cuijpe s P, an S a en A, Wa me dam L. P oblem sol ing he apies o dep ession: a me a-analysis. Eu Psychia y. 2007; 22:9-15. 41. Gualano M, Be F, Ma o ana M, Voglino G, And iolo V, Thomas R, e al. The long- e m e ec s o biblio he apy in dep ession ea men : Sys ema ic e iew o andomized clinical ials. Clin Psychol Re . 2017;58:49-58. 42. Cuijpe s P, Donke T, an S a en A, Li J, Ande sson G. Is guided sel -help as e ec i e as ace- o- ace psycho he apy o dep ession and anxie y diso de s? A sys ema ic e iew and me a-analysis o compa a i e ou come s udies. Psychol Med.