Developing a Culturally Appropriate Depression Prevention Program: Opportunities and Challenges

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    Cognitive and Behavioral Practiwarrant treatment (Kessler, Zhao, Blazer, & Swartz, 1997).The consequences of depression are considerable, produc-ing substantial human suffering and loss of productivity(Greenberg et al., 2003; Wang, Simon, & Kessler, 2003).Moreover, researchers have found that individuals whoexperience depressive episodes have an elevated risk forfuture depressive episodes (Boland & Keller, 2002).

    likely to prematurely terminate treatment (e.g., Orga-nista, Muoz, & Gonzalez, 1994; Snchez-Lacay et al.,2001). This underutilization of mental health services byLatinos is likely the result of many factors; however, it isplausible that the general lack of attention to cultureduring the intervention development process has led totreatments that are less appealing and less efficacious withAquevaridep

    1077 2Publevaluation.

    EPRESSION is one of the most prevalent and disablingpsychiatric disorders, and it affects individuals of all

    l and ethnic backgrounds. Recent estimates suggest thatroximately 16% of the general population will meetria for major depression at least once in their livesssler et al., 2005; 2006), with significant numbersriencing multiple episodes (Boland & Keller, 2002).eover, many more will experience clinically significantls of depressive symptoms that donot reach the thresholdajor depressive disorder but are sufficiently impairing to

    nately, the research that has documented pervahealthcare disparities affecting minorities in this coun(U.S. Department of Health and Human Services, 20has found that Latinos are less likely to utilize formental health services than Caucasians (Alegra et2002; Snowden & Yamada, 2005; Vega, Kolody, AguiGaxiola, & Catalano, 1999), especially if they areacculturated or recent immigrants (Alegra et al., 20Cabassa, Zayas, & Hansen, 2006; Vega et al., 199Moreover, when Latinos do seek services, they are mDeveloping a Culturally AppropriOpportunities

    Esteban V. Cardemil, Saeromi Kim, Tatiana DaMonica Sanchez, and Sa

    This paper describes the experiences of the first author and hisprevention program that specifically targets Latina mothers. Builhealth services by Latinos in general, this paper will make thdepression. In addition to the fact that depression is a highly prchildren of parents with depression are significant. Thus, thedepression a critical public health problem that calls for creatiimplementation of prevention programs. Depression prevention prthat they can be offered at a relatively low cost, can be packaged inincidence of cases that develop into clinical depression.

    This paper will describe the process of developing a novel deppaid to cultural sensitivity. We describe the complexity inherenimplementation in the development and evaluation of the prevemerge when attempting to balance the creation of a program tht least partly in response to the significant conse-nces of depression, researchers have developed aety of efficacious psychosocial interventions forression (DeRubeis & Crits-Cristoph, 1998). Unfortu-

    -7229/10/188197$1.00/0009 Association for Behavioral and Cognitive Therapies.ished by Elsevier Ltd. All rights reserved.Depression Prevention Program:d Challenges

    n, Ingrid A. Sarmiento, Rachel Zack Ishikawa,Torres, Clark University

    agues in the development and implementation of a depressionn the earlier papers that highlight the underutilization of mentalthat the situation is particularly concerning with regards tot disorder among Latino adults, the potential consequences forutilization of formal mental health services by Latinos makeslutions. One possible solution is the careful development ands have some advantages over formal mental health treatment inthat make them less stigmatizing, and if effective, can reduce the

    n prevention program, with a particular focus on the attentionefining cultural sensitivity and illustrate in concrete ways its 17 (2010) 188197Latinos (Bernal & Scharrn-del-Ro, 2001; Muoz &Mendelson, 2005). This possibility, coupled with therapid growth of the Latino population in the U.S.,highlights the importance of devoting resources to thedevelopment of novel interventions that can respond tothe needs of Latinos presenting with depression.

    Prevention programs offer one way to provide mentalhealth services to individuals who might otherwise not

  • 189Culturally Appropriate Prevention Programreceive such services. Prevention programs can beadvertised in nonstigmatizing ways (e.g., stress manage-ment programs), they can be delivered in nontraditionalsettings (e.g., schools, community centers), and they canbe delivered by non-mental-health professionals whoreceive some training (e.g., teachers, case workers). Thisflexibility in delivery format is the direct result of the needfaced by prevention programs to explicitly consider howto attract participants, as compared with treatmentinterventions that are more readily sought out byparticipants in need. Also, because of the flexibility andinnovative thinking that accompany the development ofprevention programs, they are more readily adapted forspecific cultural groups. The ability of culturally adaptedprograms to enhance the attractiveness and acceptabilityof interventions, together with the inherently lessstigmatizing nature of prevention programs, make cultur-ally adapted prevention programs a potentially importanttool in efforts to reduce mental healthcare disparities inthe U.S. (Muoz & Mendelson, 2005).

    With regard to depression, there is some evidence thatprevention efforts might be particularly effective, both inchildren and adolescents (e.g., Clarke et al., 1995; Clarkeet al., 2001; Gillham, Reivich, Jaycox, & Seligman, 1995)and young adults (Seligman, Schulman, DeRubeis, &Hollon, 1999). Moreover, some research on the preven-tion of depression in Latinos suggests that these programshave considerable potential to reduce existing symptomsand to prevent their later reemergence (Cardemil,Reivich, Beevers, Seligman, & James, 2007; Cardemil,Reivich, & Seligman, 2002; Muoz et al., 1995; Muozet al., 2007; Vega & Murphy, 1990). Targets of theseprograms have included Latino middle school childrenliving in urban environments, low-income Latino medicaloutpatients, mid-life Mexican-American women, andLatina mothers in the postpartum period. One group ofLatinos for whom a depression prevention program hasthe potential to yield considerable benefit is low-incomeLatina mothers. A variety of studies have found elevatedrates of depressive symptoms among low-income Latinamothers (e.g., Bassuk, Perloff, and Garcia-Coll, 1998;Heneghan, Silver, Bauman, Westbrook, & Stein, 1998; Le,Muoz, Soto, Delucchi, & Ippen, 2004). Moreover, thenegative effects of parental depression on childhoodadjustment have been well-established in the literature(Downey & Coyne, 1990), and emerging research hasextended this relationship to Latinos (e.g., Hovey & King,1996; Weiss, Goebel, Page, Wilson, & Warda, 1999). Thus,in addition to benefiting the mothers themselves, aprevention program for Latina mothers may also benefittheir children.

    In a previous article, we described the initial steps of aprogrammatic research effort to develop the FamilyCoping Skills Program (FCSP), a depression preventionprogram for low-income Latina mothers (Cardemil, Kim,Pinedo, & Miller, 2005). In this article, we describe morecomprehensively the process of developing a depressionprevention program that attempts to attend to culturalsensitivity in a variety of ways. We highlight some of thesuccesses of our efforts, as well as some of the challengeswe experienced. Finally, we discuss some of the challengeswe are currently experiencing while evaluating thisprogram more rigorously through a randomized clinicaltrial.

    Overview of the FCSP

    We have comprehensively described the FCSP else-where (Cardemil et al., 2005). In brief, the FCSP is aprimarily group-based cognitive-behavioral interventionthat draws upon other cognitive-behavioral preventionprograms (e.g., Muoz & Ying, 1993). There are six weeklygroup sessions, lasting approximately 2 hours each. Eachcohort includes 3 to 5 participants. The two primary goalsof the group sessions are for the participants to learn a setof concrete skills that can help them more effectivelyregulate negative emotions, and for the participants toexperience a supportive environment through exposureto other mothers who share common experiences. Eachsession combines the presentation of didactic informationwith interactive group discussion.

    In addition to the group component, the FCSPintegrates two separate family sessions into the program.Each participant and one adult family member (e.g.,spouse, partner, other supportive adult) meet with theintervention leader twice over the course of the program.The theoretical origins of the family component can befound in the McMaster Model of Family Functioning, atheoretical model that emphasizes the interrelatedness offamily members across a variety of domains (Miller, Ryan,Keitner, Bishop, & Epstein, 2000). The primary goals ofthe family sessions are to introduce the program staff tofamily members, and to provide some psychoeducationaround depression and stress, stress management, andproblem-solving.

    Summary of Results From Open Pilot Trial

    As described in Cardemil et al. (2005), we conductedan uncontrolled pilot trial with the goals of evaluating ourabili