A Randomized Hybrid Efficacy and Effectiveness Trial of Behavioral Activation for Latinos With Depression

doi:10.1016/j.beth.2014.09.011

Behavior Therapy

Volume 46, Issue 2, March 2015, Pages 177-192

https://doi.org/10.1016/j.beth.2014.09.011 Get rights and content

Highlights

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Behavioral Activation was compared to treatment-as-usual at a community clinic for Latinos with depression.
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Behavioral Activation performed well with respect to treatment engagement and retention.
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Clients who engaged in treatment and completed more sessions showed significant improvements in Behavioral Activation.

Abstract

Depression presents a significant public health burden for Latinos, the largest and fastest-growing minority group in the United States. The current study performed a randomized controlled trial of Behavioral Activation (BA) for Latinos (BAL, n = 21), with relatively minor modifications, compared to treatment as usual (TAU, n = 22) in a community mental health clinic setting with a sample of depressed, Spanish-speaking Latinos. TAU was a strong comparison condition, taking place at the same clinic, under the same guidelines and clinic protocols, with similar levels of ongoing consultation, and using the same pool of therapists as BAL. Results indicated that BAL performed well with respect to treatment engagement and retention. Regarding acute treatment outcomes, an interaction emerged between number of sessions attended and condition. Specifically, only BAL 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. Results are discussed in terms of the balance of efficacy and effectiveness issues addressed in this trial.

Section snippets

Participants

The study protocol was approved by the Institutional Review Boards of the University of Wisconsin–Milwaukee and the Sixteenth Street Community Health Center (SSCHC). Written informed consent was obtained from all clients before initiating study participation.

Participants were low-income, monolingual Spanish-speaking Latinos who were referred for psychological services at the behavioral health clinic of the SSCHC over a 9-month period. The SSCHC is a large community health center that provides

Baseline Characteristics and Assessment Retention

Table 1 presents demographic and clinical characteristics of the sample at baseline. Significant differences between the treatment groups on randomization or other demographic and clinical characteristics were not observed.

Significant attrition to research assessment at posttreatment was observed. Of the 43 clients in the original sample, 15 (34.9%) clients did not provide posttreatment data, including 5 (23.8%) BAL clients and 10 (45.5%) TAU clients. This led to concerns about outcome analyses

Discussion

This project sought to evaluate Behavioral Activation for Latinos with depression by partnering with a bilingual (English-Spanish) community medical/mental health clinic and conducting a randomized controlled trial of BAL against an ecologically valid TAU comparison condition within the clinic setting. TAU was a stronger comparison condition than most previous TAU conditions as it took place at the same clinic, under the same guidelines and clinic protocols, with similar levels of ongoing

Conflict of Interest Statement

The authors declare that there are no conflicts of interest.

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Latinxs are substantially impacted by depression. The research literature has documented barriers (e.g., stigma, limited English proficiency, and lack of transportation) contributing to the underutilization of behavioral health services among Spanish-speaking Latinxs (SSLs). Telehealth can be broadly defined as the provision of healthcare information and services through the use of telecommunications technology. Behavioral Activation (BA) has well established empirical support for reducing symptoms of depression among ethnic minority groups. The unprecedent challenges associated with accessing in-person behavioral health services during the COVID-19 pandemic have underscored the need to examine alternate methods for treatment delivery. Thus, the proposed study aimed to conduct a feasibility study to determine the viability of telehealth-delivered BA for SSLs. Twenty-five SSL participants met eligibility criteria and were enrolled in the intervention and 17 participants completed treatment. The majority of participants experienced significant improvements in depressive symptoms and positive affect. These treatment gains were sustained at one-month follow-up. The present study offers promising preliminary data to support the acceptability and feasibility of telehealth-delivered BA, with the potential to lessen barriers to care by offering readily accessible behavioral health services for depressed individuals in underserved communities.
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The aim of this study was to examine the relative effectiveness of Collaborative and Proactive Solutions (CPS) and Parent Management Training (PMT) for youth with oppositional defiant disorder (ODD) in a community setting. Based on a semistructured diagnostic interview, 160 youth with ODD (ages 7–14; 72% male; ethnicity representative of the wider Australian population) were randomized to CPS (n = 81) or PMT (n = 79) for up to 16 weekly sessions. The primary hypothesis was that participants in the CPS group, treated in a community setting, would exhibit significant improvement in ODD, equivalent to that of an evidence-based treatment, PMT. Assessment was conducted at baseline, post-intervention, and at 6-month follow-up, using independently rated semistructured diagnostic interviews, parent ratings of ODD symptoms, and global ratings of severity and improvement. Analyses were conducted with hierarchical growth linear modeling, ANCOVA, and equivalence testing using an intent-to-treat sample. Both treatments demonstrated similar outcomes, with 45–50% of youth in the nonclinical range after treatment, and 67% considered much improved. No differences were found between groups, and group equivalency was shown on the independent clinician and parent-rated measures. Gains were maintained at the 6-month follow-up. In conclusion, CPS works as effectively as the well-established treatment, PMT, for youths with ODD, when implemented in a community-based setting. As such, CPS provides a viable choice for families who seek alternate treatments.
Acceptability of Behavioral Activation for Depression Among Latinas: A Mixed Methods Study
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Latinxs represent the largest ethnoracial minority population in the United States. Despite having significant rates of depression, Latinxs underutilize behavioral health services. This, combined with the association between gender and depression (women have higher rates of depression than men), underscores the importance of developing an improved understanding of how Latinas view behavioral activation (BA), an empirically supported treatment for depression. In this mixed methods study, participants consisted of 77 Latinas; participants were provided with a vignette depicting a fictional character that underwent BA for depression. Participants in the quantitative study completed a measure of treatment acceptability of BA (n = 60); participants in the qualitative study completed a semistructured interview assessing their views on BA (n = 17). Latinas had generally positive attitudes about BA, although they also identified some elements that they perceived might act as barriers to treatment success. Because we were interested in the interplay of cultural factors and treatment acceptability, we also examined enculturation and acculturation as predictors of treatment acceptability—enculturation only was a significant predictor treatment acceptability. Our sample was relatively small, social desirability may have influenced our responses, and it is not known to what extent our results generalize to Latinx men. Latina women find BA to be an acceptable treatment for depression, which suggests promise with regard to clinical outcomes for depressed Latinas receiving BA. Addressing potential barriers to treatment engagement may improve outcomes for depressed Latinas receiving BA.
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As depression and insomnia became worse, she increased problematic drinking and began misusing opioid medication. The literature would suggest Behavioral Activation as a possible choice to treat depression (Collado et al., 2016; Kanter et al., 2015). However, given her co-occurring insomnia and marital conflict, should interventions instead be combined—by treating insomnia and depression concurrently (Manber et al, 2008; Stepanski & Rybarczyk, 2006) or combining depression treatment and marital therapy to help depression and marital satisfaction (Jacobson et al., 1991)?
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^☆: Jonathan W. Kanter is now at the University of Washington. This study was supported by NIMH Grant (R34) MH085109-01A1 awarded to Jonathan W. Kanter and Azara L. Santiago-Rivera.

View full text

A Randomized Hybrid Efficacy and Effectiveness Trial of Behavioral Activation for Latinos With Depression☆

Highlights

Abstract

Section snippets

Participants

Baseline Characteristics and Assessment Retention

Discussion

Conflict of Interest Statement

European Psychiatry

Medicina clinica

Clinical Psychology Review

Clinical Psychology Review

Psychiatry Research

Journal of Psychiatric Research

Psychiatry Research

Clinical Psychology Review

Controlled Clinical Trials

Inequalities in use of specialty mental health services among Latinos, African American, and Non-Latino Whites

Psychiatric Services

Diagnostic and statistical manual of mental disorders

Factors related to quality of life and satisfaction in nursing students

Cicencia y Enfermeria

Manual for the Beck Depression Inventory–II

Poverty and psychiatric status: Longitudinal evidence from the New Haven Epidemiologic Catchment Area Study

Archives of General Psychiatry

“It’s like being in a labyrinth:” Hispanic immigrants’ perceptions of depression and attitudes toward treatments

Journal of Immigrant and Minority Health

Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression

Journal of Consulting and Clinical Psychology

Quality of Life Enjoyment and Satisfaction Questionnaire: a new measure

Psychopharmacology Bulletin

Retention in depression treatment among ethnic and racial minority groups in the United States

Depression and Anxiety

Conceptualization and rationale for consensus definitions of terms in major depressive disorder: Remission, recovery, relapse, and recurrence

Archives of General Psychiatry

Depressive symptoms among Latino farmworkers across the agricultural season: Structural and situational influences

Cultural Diversity and Ethnic Minority Psychology

Cognitive behavior therapy has enduring effects in the treatment of depression and anxiety

Annual Review of Psychology

Quality of life in depressed women older than 40 years old

Actas Españolas de Psiquiatria

The role of nonspecific factors in cognitive-behavior therapy for depression

Clinical Psychology: Science and Practice

Clinical significance: A statistical approach to defining meaningful change in psychotherapy research

Journal of Consulting and Clinical Psychology

Behavioral Activation: distinctive features

Behavioral Activation for Latinos with Depression

Clinical Case Studies

Behavioural activation: history, evidence and promise

The British Journal of Psychiatry

Initial outcomes of a culturally adapted Behavioral Activation for Latinas diagnosed with depression at a community clinic

Behavior Modification

Barriers to Community Mental Health Services for Latinos: Treatment Considerations

Clinical Psychology: Science and Practice