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Description of client background, problem and context
When examining evidence-based, interventions to assist individuals with depression or anxiety, Cognitive Behavioral Therapy (CBT) has been used as it is deemed an effective intervention to help with depression or anxiety. However, recent studies have found that CBT might not be as effective for Hispanics or Latinos. This presents a problem because 17.8% of the Latino population in the United States is estimated to be Latino or Hispanic and 15% of those people have had a diagnosable mental illness in the past year. This represents a group of more than 8.9 million individuals (MHA, 2019). How can we ameliorate some of the symptoms these people are dealing with, when we have an evidence-based intervention that does not work on ‘their kind?’
Evidence-Based Practice Question
The evidence-based question here is the Effectiveness of CBT with Hispanics suffering from depression or anxiety.
Rationale/Significance of The Problem
More research is needed as the diversity among individuals living in the United States has rapidly increased over the past few decades. It is detrimental to ensure a respect for diversity in order to provide appropriate treatment that will have a positive effect on individuals suffering from anxiety or depression. Clinicians should demonstrate cultural competence when treating Hispanics or Latinos and this can be possibly achieved by applying an intervention that is culturally sensitive to a client’s needs.
Answer to The Practice Question
After reviewing the literature, I have concluded that CBT is a highly effective intervention for common mental health problems such as anxiety and depression. While CBT is an effective intervention, research has also shown that adapting CBT to specific marginalized or underserved groups, increases its effectiveness for those clients but this is when other factors are taken into consideration. Two of the factors mentioned in most of my body of evidence is the acculturation factor and language (affecting the therapist/client relationship). Not too many articles exist that evaluate empirically supported treatments for the mental health disorders most commonly diagnosed among Hispanics.
Appraisal of The Level of Evidence
My body of evidence included two systematic reviews and three randomized control trials.
Appraisal of The Methodological Strength/Rigor of The Body of Evidence Examined
In the Benuto and O’Donohue (2015), twelve peer-reviewed articles were reviewed to determine if culturally sensitive interventions would benefit the Hispanic population. These twelve studies were found to have significant limitations and very few used randomized control trials. This review concluded that Hispanics can be effectively treated with conventional CBT, there is a significant lack of random experimental trials, there is not much evidence that cultural adaptations can result in improved outcomes and it is not true the Hispanic culture is poorly understood. This systematic review reported that it is ridiculous to expect positive treatment outcomes if the client and therapist cannot communicate well. Culture does not necessarily have an impact on the treatment’s effectiveness but the communication between client and therapist does. It was found that the cultural modifications made to the interventions were not consistent across all 12 reviewed articles.
Naeem, Gul, Irfan, Munshi, Asif, Rashid, and Ayub (2015) conducted a randomized controlled study in which the efficacy of brief culturally adapted CBT (CaCBT) for depression was studied. The sample was selected as follows: participants with a diagnosis
of depression and attending psychiatry departments of three teaching hospitals in Lahore, Pakistan, were selected. 280 participants were screened and only 137 were randomly allocated to a CaCBT plus a treatment, group. Assessments were completed at baseline, at three months and at nine months after baseline. Measures used were, Hospital Anxiety and Depression Scale-Depression subscale, The Hospital Anxiety and Depression Scale-Anxiety subscale, Bradford Somatic Inventory and Brief disability Questionnaire. A data form was used to collect demographic and clinical information from the participants. Satisfaction was measured at the end of treatment using a visual analogue scale. Analyses were conducted using SPSS v.22. SPSS frequency and descriptive commands were used to measure descriptive statistics. SPSS explore command was used to measure normality of the data, using histograms and Kolmorogov Smirnov test. All continuous variables were compared using t-tests, and categorical variables (ex: gender) were compared using Chi Square tests. Questionnaire scores at 3 months and 9 months after baseline follow-ups were compared using analysis of covariance to adjust for baseline scores. A total of 280 patients were referred for therapy. Out of 160 patients who fulfilled the inclusion criteria during initial screening, 19 were excluded before baseline interviews were conducted, three refused immediately before baseline interview, and 137 were randomized to two groups. A total of 69 participants were randomized to the treatment group and 68 to the control group. The findings were not generalizable as more studies are needed. This article did not incorporate Hispanics but was selected by me to learn if culturally adapted CBT was effective for a non-white population.
Chavira, Stein, Rose, Bystritsky, Campbell-Sills, Roy-Byrne, Glen, Golinelli, Sherbourne, Sullivan, Lang, Welch, Bumgardner, Barrios and Craske (2014) conducted a randomized controlled study looking to find treatment engagement and response to CBT amongst Latinos with anxiety disorders in primary care. The sample for this study was gathered over a two-year period, participants were between 18 – 65 years old and recruited from 17 clinics at four different sites. Eighty individuals were Latino and 251 were non-Latino White. The majority of the Latino participants received the CBT intervention in English (n= 77). Blinded assessments of clinical improvement and functioning were administered at baseline and at 6, 12, and 18 months after baseline. Measures of engagement, including attendance, homework adherence, understanding of CBT principles, and commitment to treatment, were assessed weekly during the CBT intervention. The outcome measure was the 12-item Brief Symptom Inventory, Anxiety Sensitivity Index, the Patient Health Questionnaire for Depression, the Sheehan Disability Scale (SDS) modified to assess anxiety-related disability, the Short-Form Health Survey and a brief survey to assess satisfaction with mental health treatment for anxiety. These measures offered good internal consistency, test–retest reliability, and convergent validity. This study had a few limitations and those were that sample size was too small, engagement was probably not sufficient, and language. The sample should have been different in regard to SES, access to resources and level of acculturation. The outcomes of this study cannot be generalized for the above-mentioned reasons. The findings from this study suggest that CBT for anxiety can be an effective treatment option for Latinos who are English speaking and likely more acculturated.
Pineros-Leano, Liechty and Piedra (2017) conducted a systematic review looking at the effectiveness of cognitive behavioral therapy for depression among Latino immigrants and cultural adaptations. This review aimed to systematically review peer-reviewed articles of intervention studies that used CBT to treat depressive symptoms among Latino immigrants in the United States. Inclusion criteria were intervention studies that used cognitive behavioral techniques to treat depressive symptoms amongst a predominantly U.S. Latino immigrant sample and the use of standardized measures of depression. The National Heart, Lung, and Blood Institute quality assessment tools for systematic reviews were used to assess for risk of bias. Eleven studies met inclusion criteria and nine of these studies reported a reduction in depressive symptoms. Each study was found to use at least one cultural adaptation to deliver the intervention. The articles reviewed lacked uniformity in terms of sample size, cultural adaptations, methodological rigor and effectiveness across studies. This review concluded that culturally adapted CBT to address depressive symptoms among Latino immigrants seems to be promising but further research is needed. This review also found that the most commonly used cultural adaptations in all the reviewed studies included language, inclusion of migration experience, and adjustment for literacy level.
Kanter, Santiago-Rivera, Santos, Nagy, Lopez, Hurtado and West (2014) conducted a randomized control study in which the sample consisted of low-income participants, monolingual Spanish speaking Latinos who were referred for psychological services at a local behavioral clinic, over a nine-month period. Inclusion criteria included self-identifying as Latino, age between 18 and 65, a score of 16 or higher on the first 17 items of the 25-item modified Hamilton Rating Scale for Depression and meeting criteria for major depressive disorder according to the DSM-IV. Exclusion criteria included any problem requiring immediate inpatient hospitalization, organic brain syndrome or an intellectual or developmental disability according to medical records, probable alcohol abuse, a lifetime diagnosis of psychosis or bipolar disorder as indicated by the MINI, a current diagnosis of panic disorder as indicated by the MINI, or being on an antidepressant medication at the time of eligibility assessment. Depression severity was assessed using the first 17 items of the Spanish version of the 25-item modified HRSD. The Spanish version if the Beck Depression Inventory–II was used and has demonstrated good internal consistency. Analyses of baseline comparisons, adherence, session attendance/dropout, and response/remission/reliable change were conducted for continuous variables using analysis of variance (ANOVA) or independent samples t-tests. Fisher’s exact test was used for categorical variables. Significant attrition to research assessment at posttreatment and at follow-up assessment, was observed. Due to the high levels of attrition, this study concluded that clients who were engaged in treatment and attended more sessions demonstrated significant reductions in depression and improvements in quality of life and mental health functioning.
Appraisal of The Applicability of The Evidence
The reviewed body of evidence partially answers my question, but more research needs to be conducted. I agree that the communication barrier between the therapist who is administering CBT and the client is detrimental to the efficacy of the intervention itself, but I also agree with some of the studies which state that acculturation is a factor that must be taken into consideration when assessing for the efficacy of CBT for Latinos.
- Benuto, L., & O’Donohue, W. (2015). Is Culturally Sensitive Cognitive Behavioral Therapy an Empirically Supported Treatment?: The Case for Hispanics. International journal of psychology and psychological therapy, 15(1), 405–421. Retrieved from https://dialnet.unirioja.es/servlet/oaiart?codigo=5686537
- Chavira, D. A., Golinelli, D., Sherbourne, C., Stein, M. B., Sullivan, G., Bystritsky, A., . . . Craske, M. (2014). Treatment engagement and response to CBT among latinos with anxiety disorders in primary care. Journal of Consulting and Clinical Psychology, 82(3), 392-403. doi:http://dx.doi.org.libproxy2.usc.edu/10.1037/a0036365
- Kanter, J., Santiago-Rivera, A., Santos, M., Nagy, G., López, M., Hurtado, G., & West, P. (2015). A Randomized Hybrid Efficacy and Effectiveness Trial of Behavioral Activation for Latinos With Depression. Behavior Therapy, 46(2), 177–192. https://doi.org/10.1016/j.beth.2014.09.011
- Mental Health America (2019). Latino/Hispanic Communities and Mental Health Retrieved from: https://www.mhanational.org/issues/latinohispanic-communities-and-mental-health
- Naeem, F., Gul, M., Irfan, M., Munshi, T., Asif, A., Rashid, S., … Ayub, M. (2015). Brief Culturally adapted CBT (CaCBT) for depression: A randomized controlled trial from Pakistan. Journal of Affective Disorders, 177, 101–107. https://doi.org/10.1016/j.jad.2015.02.012
- Pineros-Leano, M., Liechty, J., & Piedra, L. (2017). Latino immigrants, depressive symptoms, and cognitive behavioral therapy: A systematic review. Journal of Affective Disorders, 208, 567–576. https://doi.org/10.1016/j.jad.2016.10.025
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