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 ourability to recruit participants into the program, and retainthem once they enrolled. We were also interested inpreliminarily examining change in depressive symptomsover the course of the program. Our results from theinitial pilot trial suggest that the FCSP was well-received byboth potential and actual participants. The majority ofparticipants were recruited from waiting rooms in healthcenters, local community organizations, and throughword of mouth. Over 75% of those initially approached bystudy recruiters expressed some interest in participating,

  • 190 Cardemil et al.and ultimately about one-third of these enrolled in theproject. Of the 33 who enrolled in the open pilot trial, 28participants (85%) attended at least three of the six groupsessions, and 24 participants (73%) attended at least fourgroup sessions. Although the family sessions were less well-attended than the group sessions, approximately 52% ofthe participants attended at least one family session.Scheduling difficulties were the primary reasons given byparticipants who were unable to attend either group orfamily sessions.

    With regard to change in depressive symptoms asmeasured by the Beck Depression Inventory (BDI; Beck,Ward, Mendelson, Mock, & Erbaugh, 1961), there was astatistically significant reduction in depressive symptomsover the course of the program. Much of this differencewas driven by the symptomatic improvement in thoseparticipants who reported mild to moderate levels ofsymptoms at baseline, a pattern that is consistent with thatreported by other depression prevention programs (e.g.,Cardemil et al., 2007; Horowitz & Garber, 2006). Inaddition, participants who attended at least one familysession reported significantly greater reduction in symp-toms than those who did not attend any family sessions.

    Given the generally positive results from the open pilottrial, we have advanced our research program to morerigorously evaluate the efficacy of the FCSP in arandomized controlled trial, which is comparing immedi-ate participation in the FCSP to a 6-month wait-listcomparison condition. In this study, we made severalchanges to the research protocol in response to ourexperiences with the pilot study. First, we establishedmoreformal inclusion and exclusion criteria. Participants areeligible to enroll if they are female, self-identify as Latina,and have a current status as the primary parental caregiverof at least one child under the age of 12. Exclusion criteriainclude individuals who are currently depressed or meetfull DSM diagnostic criteria for a variety of disorders (e.g.,substance dependence, psychotic disorders, etc.). Second,in addition to collecting self-report data from participants,we are also including interviewer-based assessments.Moreover, we are conducting assessments through6months of follow-up assessment. Third, we have engagedparticipants more fully in the process of arranging thefamily sessions. This engagement has included helpingparticipants identify obstacles to setting up family sessions,supporting participants who felt uncertain about how toinvite partners, and being particularly flexible in thescheduling of appointments. And fourth, we have devel-oped a measure of cultural competency that mirrors thetreatment literature on therapist competency in order tobegin to assess the provision of culturally sensitive deliveryof the intervention.

    To date, we have randomized 68 individuals into theprogram, and in general, we continue to receive positivefeedback from the participants on their experience in theprogram. For example, participants complete a feedbackform after each group session that contains four questionsrelevant to their experience in the session: (1) How usefuland relevant did you find the session? (2) Did you learnany new information in the session? (3) How comfortabledid you feel during the session? and (4) How comfortabledid you feel talking and sharing your experiences duringthe session? Scores are rated on a 5-point Likert scale, withhigher scores indicative of more positive experiences.Across the 34 participants randomized to the immediatecondition, the mean scores were very high (Question 1:x_=4.94, SD=0.26; Question 2: x_=4.79, SD=0.44; Question3: x_=4.96, SD=0.21; Question 4: x_=4.92, SD=0.27). Inaddition, participants generally provided very positivecomments. Many participants commented on the sup-portive atmosphere. One participant said, Todas estamoscomo en familia (We are like in a family). It's fun, It's likewe've met and shared a lot of the same problems.Another participant reported, Me sent bien pues encontrconfianza en todas las participantes como en las que dirigen elgrupo (I felt good, as I found trust among all theparticipants and among those who lead the group).Participants also commented on the utility of the skillsdiscussed in the sessions. One participant said, Me gustsaber que podemos medir las emociones. El termmetro [emocio-nal] es algo nuevo para mi (I liked knowing that we canmeasure our emotions. The [emotional] thermometer issomething new for me). Another participant stated,Aprend como mejor cambiar los pensamientos pesimistas poroptimistas (I learned how to better change my pessimisticthoughts to optimistic ones).

    The positive responses on the feedback form havebeen mirrored by...


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