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Cognitive and Behavioral Practice 15 (2008) 67–75www.elsevier.com/locate/cabp

A Pilot Study of Culturally Adapted Cognitive Behavior Therapyfor Hispanics with Major Depression

Alejandro Interian, Lesley A. Allen, Michael A. Gara, and Javier I. EscobarUMDNJ—Robert Wood Johnson Medical School

1077© 20Publ

The purpose of this study was to evaluate a culturally adapted cognitive-behavioral treatment (CBT) for major depression amongHispanics in primary care. Cultural adaptations were applied based on a range of cultural considerations described in the literature.Fifteen Hispanic primary care patients with major depression were enrolled. All participants received the 12-session intervention andcompleted baseline, posttreatment, and 6-month follow-up assessments. Four participants (27%) dropped out of the treatment. Analysesfocused on changes from baseline functioning using a Wilcoxon Signed Rank Test. Results showed significant reductions in depressive,anxious, and somatic symptoms at posttreatment and 6-month follow-up. Mean reduction of depressive symptoms at posttreatment was57%. Findings of acceptable treatment retention rates and clinically meaningful reductions in depressive symptoms showed promise forthis intervention to treat Hispanics with major depression. Future studies should conduct a more rigorously controlled evaluation of thisintervention.

MAJOR DEPRESSION is a prevalent disorder that hasbeen estimated to be a leading cause of disability

worldwide (Murray & Lopez, 1996). Lifetime prevalenceis 6% to 17% in the general U.S. population and 3% to18% among U.S. Hispanics (Karno et al., 1987; Kessleret al., 1994; Kessler et al., 2003; Vega et al., 1998). AlthoughHispanics represent 13% of the U.S. population and havebecome the largest U.S. minority group (Ramirez & de laCruz, 2003), Hispanics and other minority groupsexperience disparate mental health care in comparisonto non-Hispanic Whites (Department of Health &HumanServices [DHHS], 2001). The disparity involves pooreraccess to services and poorer quality mental health care.

This problem is likely related to a number of factors,such asmental health care costs, stigma, language barriers,and clinicians' lack of cultural knowledge (DHHS, 2001).In addition, there is a dearth of empirical researchexamining treatment outcome among this group, anissue discussed in a supplement to the Surgeon General'sreport on mental health (DHHS, 2001). Specifically, thereport summarized randomized controlled trials that wereconducted during a 10-year period since 1986 for majordepression, bipolar disorder, schizophrenia, and atten-tion-deficit/hyperactivity disorder. Of the nearly 10,000patients who participated in these trials, ethnic informa-tion was noted for only half of them. In addition, only 99

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participants were identifiable as Hispanic, and none ofthese were included in any of the depression trials. Asimilar pattern of underinclusion was observed amongother minority groups. The lack of empirical studies withHispanics and other minorities was also addressed in aspecial issue of the Journal of Consulting and ClinicalPsychology in 1996 (Miranda et al., 1996) andmore recentlyin a paper describing the persistence of this problem(Miranda, Nakamura & Bernal, 2003). The lack ofsufficient studies underscores the need to expand theresearch base to include outcome studies for majordepression among Hispanics, thereby helping to reducethe disparities that exist for this group.

Cognitive-Behavioral Treatment (CBT) for MajorDepression Among Hispanics

Relatively few studies have examined CBT for majordepression among Hispanics. This body of researchprovides important preliminary findings given that CBThas been recognized as a front-line treatment for majordepression among nonminorities (DHHS, 2003). Also,some evidence has indicated that Hispanics tend to preferpsychotherapy over pharmacotherapy (Alvidrez & Azocar,1999; Cooper et al., 2003). Therefore, a close examinationof the application of CBT for major depression amongthis group is warranted.

According to the literature since 1981, five trials ofCBT for Hispanic patients with major depression havebeen conducted. Of these, two focused solely on Hispanicparticipants (Comas-Diaz, 1981; Rossello & Bernal, 1999).

68 Interian et al.

Three included a significant portion of Hispanics alongwith participants from other minority groups (Miranda,Azocar, et al., 2003; Miranda, Chung, et al., 2003; Organistaet al., 1994). All demonstrated that Hispanics with majordepression benefited from CBT. However, the level ofsymptom reduction from the therapy seemed lower incomparison to studies conducted with non-Hispanicsamples. Among the CBT studies with Hispanics reviewed,the depressive symptom reduction percentage at posttreat-ment ranged from 20% to 64%. Comas-Diaz (1981)reported the mean reduction of depressive symptoms tobe 64% for cognitive therapy and 51% for behavior therapy.Other mean depressive symptom reductions were 34% byRossello and Bernal (1999), 30% by Miranda, Azocar, et al.(2003), 28% by Organista et al. (1994), and 20% byMiranda, Chung, et al. (2003). In contrast, one review ofstudies with non-Hispanic samples showed a range of 42%to 84%(Hollon et al., 1991). Also, treatment retention ratesin theCBTstudies withHispanics appear problematic (36%to 83%). By comparison, the same review of CBToutcomeamong non-Hispanics showed higher treatment retentionrates (62% to 95%; Hollon et al., 1991).

Regarding longer-term outcomes, the picture is a bitmore mixed. Some studies with Hispanic populationsfound continued reductions of depressive symptoms atfollow-up (Miranda et al., 2006; Rossello & Bernal, 1999)and one showed follow-up symptom levels that werecomparable to those at posttreatment (Miranda, Azocar,et al., 2003). Comas-Diaz (1981) found that treatmentgains were reduced at follow-up with cognitive therapy, butthat symptom reductions continued for behavior therapy.

One study suggested that making certain enhancementstoCBT formajor depression amongHispanicsmay improvetreatment retention rates. The enhanced intervention, CBTsupplemented with case management, was designed toaddress the multiple stressors experienced by segments ofminority communities (Miranda, Azocar, et al., 2003).Specifically, case management included ongoing supportwith psychosocial stressors (e.g., housing difficulties). Parti-cipants (39% Hispanic) were randomly assigned to receive12 sessions of group CBT versus 12 sessions of group CBTsupplemented with casemanagement. Among theHispanicparticipants, the treatment retention rate was 60% for thosereceiving CBT alone and 83% for those receiving CBTwithcase management. Among Hispanic participants, de-pressive symptom reduction was greater for those receivingCBT supplemented with case management (30%) thanCBT alone (18%). Thus, additions made to CBT appro-aches may be associated with better outcomes amongHispanics with major depression. As a whole, the literaturesuggests that further research is needed to improve theapplication of CBT for Hispanics with major depression.

The literature provides culturally relevant findings thatcan serve as the basis for making such improvements.

Primary examples include the relevance of acculturation interms of risk for major depression (Vega et al., 1998), theoverutilization of primary care for mental health needs(DHHS, 2001; Vega et al., 1999), andhigher rates of somaticsymptoms associated with major depression (Escobar et al.,1989; Guarnaccia et al., 1989; Myers et al., 2002). Othercultural differences that need to be accounted for includeinterpersonal styles that emphasize likability and positiveinteractions (simpatia; Triandis et al., 1984) and the role of astrong family orientation (familismo; Sabogal et al., 1987).

The overarching goal of the current study was to addressthe disparities found among research studies focusing onHispanic patients. We describe pilot data on a 12-sessionindividual CBT treatment for major depression with His-panics. Our participants were primarily low-income, non-English-speaking primary care patients from various LatinAmerican countries. The current study sought to expandour knowledge of CBT for Hispanics withmajor depressionin a number of ways. First, the intervention focused onconcrete strategies for adapting traditional CBT appro-aches (e.g., Beck et al., 1979) for depression amongHispanics. These adaptations were formulated from ourexperience working with Hispanic patients in primary care,as well as from cross-cultural considerations described inthe literature (e.g., Comas-Diaz & Duncan, 1985; Muñozet al., 2000; Organista, 2000; Organista & Muñoz, 1996).Second, our study examined the preliminary efficacy ofCBT that was provided in primary care. Third, the treat-ment examined in this pilot study was designed and appliedas an individual treatment, whereas prior CBT trials amongHispanics with major depression have examined primarilygroup-based CBT approaches.

Method

ParticipantsParticipants were Hispanic patients with major depres-

sion who sought treatment at a primary care center incentral New Jersey. They were seen at the primary carehealth center, which served a large proportion of low-income minority patients. Primary care staff referredparticipants to the study if a physician noted depressivesymptoms and participants endorsed depressive symp-toms on the Personal Health Questionnaire screenerfrom the PRIME-MD (Spitzer et al., 1994).

Inclusion criteria included being between the ages of18 and 65 and having a diagnosis of major depression. Inaddition, participants were excluded if they were inconcurrent psychotherapy, had a diagnosis of bipolar orpsychotic illness, were actively abusing substances, hadclinically significant suicidal risk, or had an unstablemedical illness. One participant was concurrently takingantidepressant medication for a period of several months,thereby allowing possible improvement to be attributed tothe current treatment.

69Uncontrolled Trial of Culturally Adapted CBT

A total of 29 adults were referred to the treatmentstudy. Fourteen of these participants were excluded fornot meeting criteria for major depression (6), concurrentmental health treatment (2), and unstable major medicalcondition (2). Only 1 participant declined to enroll in thetreatment study and 3 were not enrolled due to difficultycontacting/scheduling. The remaining 15 patients wereenrolled in the study.

Measures

Structured Clinical Interview for Axis I Disorders (SCID).Psychiatric diagnoses were assessed at baseline using theSCID (First et al., 1998). The SCID interview was used toensure that participants met criteria for major depressivedisorder and did not present with psychiatric symptomsthat would have required exclusion from participating(e.g., active substance abuse).

Beck Depression Inventory–Spanish (BDI-S). The primaryoutcome measure utilized was the BDI-S (Bonilla et al.,2004). The BDI-S is a Spanish-language questionnaire thatwas adapted from the BDI (Beck & Steer, 1993) for usewith Spanish-speaking populations. The BDI-S contains 22items and total scores range from 0 to 66. The currentstudy used the BDI-S to measure participant change indepressive symptomatology. The BDI-S received supportfor its internal consistency (α= .88). Also, it convergedwith other measures of depression (r= .62 and r= .69) anddysfunctional cognitions (r= .40 and r= .52). Its factorstructure was supported with a four-factor solution thatrepresented relevant domains for depression (i.e.,somatic, sadness or hopelessness, poor self-esteem, andnegative thoughts).

Beck Anxiety Inventory (BAI). The Spanish-languageversion of the BAI was used to measure changes inanxiety symptoms across time (Beck et al., 1988). The BAIcontains 21 items and the total scores range from 0 to 63.The BAI has been reported to have comparable levels ofinternal consistency when administered in English andSpanish to bilingual Hispanics (.95 and .94, respectively;Novy et al., 2001). A correlation of .85 was reportedbetween the English and Spanish versions. The sameresearch group reported that the BAI converged withgeneralized anxiety disorder severity in Hispanics andthat its relationship to generalized anxiety disorder wasnot significantly different between language of adminis-tration (Hirai et al., 2006). Also, the BAI factor structurewas similar between Latino and Caucasian collegestudents (Contreras et al., 2004).

Patient Health Questionnaire–15 (PHQ-15). The PHQ-15(Kroenke et al., 2002) is the somatic symptom module ofthe Patient Health Questionnaire (Spitzer et al., 1999)and was used as a measure of somatic symptoms, given therelevance of such symptoms among Hispanics (e.g.,Escobar et al., 1989). The PHQ-15 score ranges from 0

to 30. It has received some support for use with Hispanicpopulations, where it was found to be related to medicallyunexplained symptoms, physical functioning, and psy-chiatric distress (Interian et al., 2006). However, the PHQ-15 exhibited a different validity profile among Hispanics,calling into question its use as a culturally comparativetool.

Procedure

After being referred by their primary care physician,participants were prescreened by telephone to ensurethey met basic eligibility criteria (e.g., age, no concurrenttreatment). A baseline assessment was subsequentlyconducted by the first author and included informedconsent and assessment using a demographic form, SCID,BDI-S, BAI, and PHQ-15.

Participants began the 12-session CBT treatment1 week after completing the baseline assessment. Post-treatment and follow-up assessments (conducted 6monthsafter completing treatment) involved readministering theBDI-S, BAI, and PHQ-15. These assessments were con-ducted by the first author or the primary-care socialworkers. All assessments and interventions were con-ducted in Spanish. The majority of participants preferredto have the outcomemeasures (i.e., BDI-S, BAI, and PHQ-15) administered by the clinicians versus completing byself-report.

Treatment

The treatment was conducted by the first author andconsisted of 12 sessions of culturally adapted CBT.Sessions were typically held weekly at the primary careclinic, were of 1-hour duration, and were administeredindividually.

Overview of treatment. A treatment manual was utilizedthat specified the therapeutic tasks to be completedduring each session. The treatment manual was organizedsuch that the first six sessions generally focused onbehavioral interventions, while the remaining six focusedon cognitive interventions. This sequence was appliedgiven evidence suggesting that behavioral approaches canactivate cognitive improvements (Jacobson et al., 1996).The treatment strategy presented to participants focusedon the recognition of cognitive and behavioral factors thatlead to the downward spiral of depression (Beck et al.,1979; Muñoz et al., 2000). Using the context of thedownward spiral, behavioral and cognitive strategies wereintroduced as tools to combat the cycle of depression.

Behavioral strategies were varied and were selectedaccording to the presenting problems of participants.They primarily included increased engagement in plea-surable/functional activities (Beck et al., 1979; Muñozet al., 2000), assertiveness training (Comas-Diaz & Dun-can, 1985), and relaxation training. Participants were

70 Interian et al.

also helped to modify recurrent, maladaptive behavioralpatterns.

Cognitive interventions involved helping participantsidentify and challenge their maladaptive cognitions (Becket al., 1979). The process of identifyingmaladaptive thoughtsbegan at the beginning of treatment, but participants werenot taught todispute their thoughts untilmid-treatment (i.e.,Session 6). This allowed for ample time to focus simply onidentifying maladaptive thoughts. It also allowed for acollection of participants' thought patterns to be availableprior to disputing them, thereby allowing a determination ofwhich thoughts weremost evocative of negative mood (Becket al., 1979; Persons, 1989).

Cultural considerations. In addition to providing CBT inSpanish, the treatment implemented cultural considera-tions for CBT with Hispanics (Interian & Diaz-Martinez,2007). An understanding of the cultural factors that comeinto play for a particular case was generated using anethnocultural assessment (Jacobsen, 1988), whichinvolved inquiring about participants' number of yearsin the U.S., their adaptation to the migration, where-abouts of family members, and changes in social support,to name a few examples. Cultural considerations alsofocused on interpersonal styles. For example, overtlywarm and positive interactions were emphasized (simpa-tia; Triandis et al., 1984). Common values, such as respeto(respect) and poniendo de su parte (putting one's part), alsoserved as considerations in treatment. For example,Comas-Diaz and Duncan (1985) has described adapta-tions for assertiveness training for patients whose socialenvironments are characterized by the need to showrespect for others. These adaptations include helpingpatients generate assertive statements that acknowledgethe importance of respect.

Language considerations were also made. In additionto providing treatment in Spanish, phraseology com-monly used by participants to describe therapeuticphenomena was emphasized. For example, desahogo(getting things off one's chest) and distraccíon (distrac-tion) are common terms used to describe the benefits oftreatment (Interian & Diaz-Martinez, 2007; MartinezPincay & Guarnaccia, 2007; Organista, 2000). While thetheoretical basis for activity increases relates to increasingthe likelihood of positive reinforcement, participants verycommonly describe the benefit as related to distractionfrom problems. Similarly, the use of dichos (sayings) tocomplement the explanation of therapeutic techniques isanother way to hold a more consonant discussion betweenthe therapist and patient (Bernal et al., 1995; Interian &Diaz-Martinez, 2007; Zuniga, 1991).

Considerations were also made in applying cognitiveand behavioral techniques. Organista & Muñoz (1996)described a technique for simplifying cognitive disputa-tion exercises. With the “yes…, but…” technique, partici-

pants are prompted to generate statements that countertheir maladaptive thoughts, thereby incorporating adap-tive thoughts that were being filtered out. Also, Marin(1991) described the importance of understanding thebehavioral repertoires of patients, given the varyingpractices associated with different cultures and levels ofacculturation. Therefore, questioning was used to exam-ine the types of behaviors and activities that were relevantfor patients, given their backgrounds, goals, and socialenvironment. Inquiring about common activities in theirsocial environment provides information on what may benormative and highlights potential activities in whichpatients may become involved. Attention was also given tovalues that may impede certain types of behavioralchanges. For example, a common occurrence is whenfamilismo inhibits participants' willingness to take time forthemselves to engage in pleasurable activities (Organista,2000). In these cases, their independent time wasreframed as necessary for the family, given that improvingtheir depression would lead to better family functioning.Alternatively, activities were selected that were family-oriented. Furthermore, a CBT case-conceptualizationapproach was applied in order to target the multiplestressors that are more likely experienced by lower-income minority participants (Persons, 1989). The case-conceptualization approach sought to help participantsby developing a unified CBT conceptualization thataccounted for various ongoing problems and stressors.

Other cultural considerations guided the treatment. Theintervention was provided in primary care to match acommon treatment utilization pattern of seeking mentalhealth services in primary care (DHHS, 2001). The clinic wascentrally located,which facilitated transportation. Also, whensomatic concerns were presented, therapeutic techniquesshown to have an effect on physical symptoms were utilized(e.g., relaxation techniques, sleep hygiene, increased physi-cal activity; Allen et al., 2006; Woolfolk & Allen, 2007).

Case Examples

Case example 1. Ana was a 22-year-old single female whospoke limited English and immigrated 3 years prior fromMexico. She attributed her depressive symptoms toconflicts with her mother and described feelings ofanger due to what she described as constant criticismand overly restrictive parenting. She also complained ofunderperforming at school and a general sense ofisolation and loneliness. As a result of her conflicts withher mother, she transitioned into her own housing andthey began to have minimal contact.

We discussed her cycle of depression and the emo-tional, behavioral, and cognitive implications of notengaging in sufficient activities, thereby generating aplan for increasing her level of activity. Interventions usedlater in treatment included cognitive disputation and

71Uncontrolled Trial of Culturally Adapted CBT

assertiveness training. Overall, Ana was engaged intreatment and seemed to understand the rationalesbehind the skills addressed in treatment. She increasedher behavioral engagement, learned to combat recurrentmaladaptive thoughts, modified recurrent maladaptivebehaviors, and increased her assertiveness. Her BDI wentfrom a 33 at baseline to a 5 at posttreatment.

There were a number of cultural considerations thatguided the treatment. While Ana was primarily Spanishspeaking, a number of indicators suggested that she wasacculturating (e.g., non-Hispanic peer group, rate ofEnglish acquisition). At the same time, she describedmany values that tend to be traditionally Hispanic, such asrespeto for adults and familismo. As a result, Ana wasdeveloping a bicultural identity that included commonbeliefs and practices of U.S. society, as well those of hernative country.

Intergenerational conflicts among families who haveimmigrated are not uncommon (Organista, 2000). Con-flicts are fueled when different family members adopt newvalues and practices at different rates. While this is acommon phenomenon, it was important to not assumethat parental conflicts always occurred for this reason.Therefore, inquiry was directed toward school-relatedbehavior difficulties, the types of activities Ana shared withher friends, the use of substances, and other indicatorsthat may suggest problematic behavior. Our discussion ofthese topics provided no evidence of problematic,impulsive, or self-destructive behaviors. The issue wastherefore treated as one of conflicting values.

While exploringactivity increases, it was important to targetbehaviors that were within Ana's desired repertoire andencompassed her increasingly bicultural identification. Thus,while spending time with friends and planning for a degreeprogram were activities to be increased, there was also anapparent need to maintain relationships with her family,especially those still living inMexico. Accordingly, some of heractivity increases included more contact with her family inMexico. Also, her desire to spendmore timewith her youngersister, who continued to reside with the mother, providedinitial motivation for Ana to begin reengaging with hermother. This motivation translated into increased behavioralengagement with her family. It also included assertivenesstraining that was adapted to include acknowledgement ofrespeto (e.g., “Mom, I know that it is important to respect you,but I would like to say …”).

Finally, understanding the impact of migration isessential. It allows for a better understanding of the issuesthat come into play with a particular set of problems. InAna's case, she exhibited core beliefs related to a sense ofdisconnection from others that were, in part, related toher move to the U.S. Understanding the impact ofmigration was also helpful while exploring alternativecognitions related to her relationship with her mother.

Specifically, although hermother's behavior was perceivedas difficult, it was useful to reframe aspects of her behavioras related to the hardship of adapting to the migration, asopposed to being intently punitive toward Ana.

Case example 2. Jose was a 40-year-old, married, Spanish-speakingmale who hadmoved to the U.S., fromColombia18 years ago. Five years prior to beginning treatment, hewas diagnosed with a rare medical condition that causedsignificant physical disability and muscle pain, whichresulted in his unemployment. His depressive symptomsappeared related to the impact that his condition had onhis life. Typical depressive symptoms were accompanied byconsiderable irritability with his family that led to socialisolation and relationship conflicts.

We discussed his cycle of depression, which wasinfluenced by muscle pain, fatigue, irritability, boredom,thoughts that his life is unsatisfactory, and tension. Josedescribed how these led to reduced activity and inter-personal conflicts, which further perpetuated the pro-blem. After examining his symptom logs, we begantraining with progressive muscle relaxation to target hisfeelings of tension and improve his muscle pain. Wehypothesized that this would improve his engagement inactivities, because he often described physical tension as areason for avoiding them. Increasing Jose's relaxation andpain-management skills allowed for behavioral engage-ment strategies to be later introduced.

Jose also presentedwith a number of cultural factors thatrequired consideration. Despite his 18 years in the U.S., hepresented with fewer indicators of acculturation. His socialnetwork was primarily Hispanic and his values remainedgenerally traditional. This affected his appraisal of hisphysical limitations. Jose, who formerly worked in construc-tion, espoused a traditional male role of being thehardworking provider who ensured a good direction forthe family and provided discipline. This value guided theactivity increases by emphasizing those that may lead tooccupational/productive roles compatible with his physicallimitations.

Furthermore, although Jose initially presented asdisengaged from family, an exploration of his familyrelationships (including extended family) was emphasizedthroughout treatment. As a result, we discovered cognitiveand behavioral patterns that impeded more functionalfamily relationships. For example, his irritability led tonegative cognitions toward his family. He perceived thathis family “bothered” him too much with frequentrequests that were difficult for him to carry out due tohis physical limitations. His responses to these difficultieswere predominantly avoidant. However, discussionrevealed that his family relationships were quite importantto him (familismo) and that he disliked the sense ofdisconnection associated with his avoidance. Assertivenesstraining was utilized to increase his family functioning.

Table 1

Participant Characteristics (n=15)

OriginMexico 6 (38.00%)Caribbean 4 (25.00%)Central America 3 (18.00%)South American 2 (13.00%)

Age 36.73 (11.19%)Female 14 (93.33%)Married 5 (33.33%)Education

7th grade or less 4 (26.67%)Jr. High—partial HS 3 (20.00%)HS diploma (or equiv) 4 (26.67%)Partial college/ trade sch 2 (13.33%)2 yr college/trade sch degree 2 (13.33%)

Spanish primary lang 14 (93.33%)Foreign born 15 (100.00%)Number of comorbid Axis I diagnoses 1.5 (.76%)Number of years in U.S. 9.8 (7.50%)Number of participants with more than

one Axis I Diagnosis5 (33.33%)

Note. Frequencies are reported with percentages in parentheses.Age, number of years in US, and number of comorbid Axis Idiagnoses are reported with mean and standard deviation inparentheses.

72 Interian et al.

Assertiveness statements were adapted to acknowledge theneed to be family oriented, given that this value wasimportant for Jose and his family.

Jose's more traditional values were also related toconflicts with his daughter. He had more restrictiveexpectations that clashed with her “Americanized”behaviors, such as talking for many hours on thetelephone. The result was increased arguing, interactionscharacterized by negative affect, and negative cognitionsabout his daughter (e.g., “She's headed down the wrongtrack”). Cognitive exercises eventually revealed that hisdaughter did quite well with school, had few, if any,behavioral problems, and that this represented what hemost desired from her. Their conflicts were compoundedby a minimal engagement of adaptive behaviors with hisdaughter (e.g., quality time, meaningful conversations,etc.) and an overemphasis on discipline. Therefore, onegoal of treatment included increasing behavioral engage-ment with his daughter in the form of assertive statementsof positive feelings and increased engagement in non-conflictual conversation.

Occasionally, Jose presented to sessions with the needto express a great deal of what he was feeling/experien-cing. This is invariably a common experience in psycho-therapy. However, it has been observed that being able to“get things off one's chest” (desahogo) is a commonly des-cribed benefit of psychotherapy among Hispanic patients(Interian & Diaz-Martinez, 2007; Martinez Pincay andGuarnaccia, 2007). In these instances, the CBT structureof the session was therefore set aside. After his difficultweek and need to get things off his chest was reflected, thereturn to the CBT structure was presented by stating, “Let'sgo back to these exercises to see if we can help you withthat.”

As treatment progressed, Jose gradually became moreactive, particularly with pleasurable activities (e.g., com-puter classes) and family activities. He increased his use ofassertive statements and engagement with his family. Asnoted, assertiveness with his daughter emphasized expres-sion of positive feelings, while communication of needsand setting limits was emphasized with his parents andextended family. By the end of treatment, he no longermet criteria for major depressive disorder. His BDI scoreat baseline was 41, which was then reduced to 2 atposttreatment and 7 at follow-up.

Results

Table 1 summarizes the characteristics of the sample,which included mostly female and monolingual Spanishspeakers who were born outside of theU.S. Approximatelyhalf of the sample included participants with limitededucational levels. Four of the 15 (27%) participants whowere enrolled in the study dropped out. Of the 4 whodropped out, 2 were due to lost contact, 1 was related to

symptom improvement and attainment of employment,and 1 was due to lack of improvement (after Session 6).For 3 of these participants, analyses were conducted usingtheir baseline data (i.e., last observation carried forwardmethod; LOCF). Posttreatment assessment data wereobtained for 1 participant who dropped out. Six partici-pants (40%), including the 4 who dropped out, could notbe assessed at the 6-month follow-up point. The LOCFmethod was also used for the follow-up assessment point.

Table 2 displays the mean scores on the outcomemeasures at pretreatment, posttreatment, and 6-monthfollow-up. This is presented separately according to intentto treat (i.e., LOCF) and treatment completers. However,the focus will be on intent to treat (LOCF) analyses asthese are the more conservative estimates of the treat-ment's effect. Changes from baseline levels of symptomswere evaluated using a Wilcoxon Signed Rank Test, giventhat the analysis involved repeated measures with a smallsample and outcome scores were not assumed to be nor-mally distributed. Participants' mean depression scores(BDI) were reduced by 19.3 points (57%) at posttreatment,a statistically significant change from baseline (T1, 14=39,p=.0005). At 6-month follow-up, the mean BDI scoresremained reduced by 18.2 points (54%) from baseline,which was also statistically significant (T1, 14=39, p=.0005).The difference in BDI scores between posttreatment andfollow-up was not statistically significant (T1, 14= -10.5,p=.25). An effect size calculation based on the mean

Table 2Mean scores across assessments points

Measure Baseline Posttreatment 6-monthfollow-up

Intent to TreatAnalysis

(n=15) (n=15) (n=15)BDI⁎ 33.53 (7.12) 14.27 (14.35) 15.53 (13.34)BAI⁎ 28.27 (15.62) 9.33 (10.53) 10.26 (10.31)PHQ-15⁎ 14.78 (4.93) 8.60 (5.09) 9.26 (4.73)

Treatment CompleterAnalysis

(n=15) (n=12) (n=9)BDI⁎ 33.53 (7.12) 8.50 (7.73) 7.89 (3.10)BAI⁎ 28.27 (15.62) 6.17 (4.15) 7.33 (4.18)PHQ-15⁎⁎ 14.78 (4.93) 6.83 (3.81) 8.67 (3.61)

Note. ⁎Posttreatment and 6-month follow up scores were allsignificantly reduced from baseline. ⁎⁎Posttreatment scores allsignificantly reduced from baseline. Treatment completer groupincludes one participant who completed half of the interventionbefore dropping out.

73Uncontrolled Trial of Culturally Adapted CBT

baseline BDI score, the mean posttreatment BDI score, andthe baseline standard deviation is 2.71. The effect size forthe baseline and follow-up differences is 2.53.

A similar pattern was observed for reductions in anxietysymptoms (BAI) and somatic symptoms (PHQ-15). MeanBAI scores were reduced by 18.9 points (67%) atposttreatment and remained reduced by 18 (64%) pointsat 6-month follow-up. Both of these score reductions werestatistically significant (T1, 14=39, p= .0005; T 1, 14=39,p=.0005). Posttreatment and follow-up assessment changeswere not statistically significant (T1, 14= -5.5, p=.41). Effectsizes were 1.21 and 1.15 for the BAI changes at post-treatment and follow-up, respectively. Significant changeswere also noted across time for PHQ­15 scores. The meanPHQ-15 score was reduced by 6.2 points (42%) at post-treatment andwasmaintainedwith a reduction of 5.5 points(37%) at follow-up. These changes were significant atposttreatment (T1, 13=22.5, p=.004) and 6-month follow-up(T1, 13=27.5, p=.01). The PHQ-15 changes between post-treatment and follow-up assessments were not statisticallysignificant (T1, 14=−7, p= .43). For the PHQ-15, the effectsizes were 1.26 and 1.12 for changes at posttreatment andfollow-up, respectively.

Results were similar among treatment completers.Significant reductions were found on all of the measuresat posttreatment and these reductions were maintained at6-month follow-up. The one exception is the PHQ-15score at follow-up, which only approached significance.

Furthermore, a descriptive analysis was conducted todetermine whether outcome assessments were affected bythe clinician who administered them. Of the 12 partici-pants for whom posttreatment data were collected, 4 wereassessed by the primary care social workers. Because these

were the treatment completers, mean BDI score reduc-tions are higher than reported above. The mean BDIscore reduction was 25.5 points (76%) when the evalua-tion was conducted by the therapist (n=8) and 21.25points (70%) when conducted by the clinical socialworkers (n=4). The symptom reductions between thesetwo groups appeared quite similar, suggesting that thefindings were unrelated to the evaluating clinician.

Discussion

The current results pertain to Hispanic patients whomeet DSM-IV criteria for major depressive disorder, havelow incomes, and are primarily Spanish-speaking. From afeasibility standpoint, the current pilot study supportsfurther examination of a culturally adapted CBT inter-vention for Hispanics with major depression in primarycare. We found that the treatment studied was feasible interms of recruitment (only one participant declined toenroll), as well as retention. In fact, the current retentionrate of 73% is favorable in comparison to other ratesreported in the literature (36% to 52%; Miranda, Chung,et al., 2003; Organista et al., 1994; Rossello & Bernal, 1999)and comparable to the 83% reported by Miranda, Azocar,et al. (2003).

Regarding preliminary efficacy, of the participants whocompleted the treatment, 67% responded to the treatmentwith a BDI reduction that was 50% or greater. Also, a slightmajority (53%) recovered from their depressive disorder(i.e., had a BDI b 9 at posttreatment). The mean reductionof BDI scores at posttreatment was 57%, which falls withinthe upper range of rates reported amongHispanics (20% to64%; Comas-Diaz, 1981; Miranda, Chung, et al., 2003;Miranda, Azocar, et al., 2003; Organista et al., 1994; Rossello& Bernal, 1999). The current mean depressive symptomreduction also falls within the range of that reported amongnon-Hispanics (42% to 84%;Hollon et al., 1991).Moreover,results show that treatment gains were maintained at 6-month follow-up and were observed on all outcomemeasures. In particular, a significant reduction of somaticsymptoms was noted, which is an important finding in lightof the heightened role that somatic symptoms have beenreported to play amongHispanics with depression (Escobaret al., 1989; Guarnaccia et al., 1989; Myers et al., 2002).These preliminary results indicate that the interventionstudied may hold promise for achieving better outcomeswith Hispanic patients with major depression and warrantsa more controlled examination.

Various cultural considerations described in the litera-ture were integrated into the current intervention (e.g.,Comas-Diaz, 1985; Interian & Diaz-Martinez, 2007; Muñozet al., 2000; Organista, 2000; Organista & Muñoz, 1996).Based on these pilot results, many of these culturalconsiderationsmay be clinically beneficial. We recommendthat clinicians complementCBTworkwith anethnocultural

74 Interian et al.

assessment to better understand the unique culturalvariables that are relevant for a particular patient.Subsequent cultural adaptations should be guided by thisassessment. For example, discrepancy levels between theacculturation of a particular patient and their socialnetwork will vary from patient to patient. Accordingly,understanding the significance of this role will determinewhether this will play amajor role in the treatment. Also, it isvery likely that fluency in Spanish is required for therapiststo workwithpatients who speak only Spanish, particularly tocapitalize on the use of culturally relevant language (e.g.,dichos, phraseology). We hypothesize that these culturaladaptations contributed to the outcomes, as well as theretention rates. Moreover, providing treatment in primarycare and in a centralized location may have enhanced ourtreatment retention rates. We also made significant effortsto encourage treatment participation. For example, it wasnot uncommon for the therapist to contact participants atthe appointment time if they had not yet arrived. In themajority of these instances, participants were able to arrivefrom their nearby homes shortly after or schedule analternative appointment. During these encounters, theinterpersonal style emphasized making the remindersfriendly, empathizing with their difficulty in making theappointment, and encouraging their attendance in termsofimproving their depression.

The current study has a number of limitations that areinherent with an uncontrolled pilot study using a smallsample size. These limitations include the lack of controlfor clinician and participant expectation, natural recoveryof depression, and effects related to clinical attention.Also, although the intervention was conducted by a singletherapist, the uniformity of the treatment cannot beensured due to the lack of treatment fidelity ratings.Finally, because of the small sample size, results of thestatistical analyses are more tentative. Therefore, thecurrent findings are preliminary and require replication.

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This work was supported, in part, by a grant from the National Alliance

for Research on Schizophrenia and Depression (NARSAD).

Address correspondence to Alejandro Interian, Ph. D., Departmentof Psychiatry, UMDNJ—RobertWood JohnsonMedical School, 675HoesLane D305, Piscataway, New Jersey, 08854; e-mail: interial@umdnj.edu.

Received: July 12 2006Accepted: December 6 2006Available online 12 February 2008