Culturally Adapted Psychotherapeutic Interventions for Latino Depression and Anxiety: A Meta-Analysis

Abstract

Objectives:

Culturally adapted psychotherapeutic interventions have been developed to treat Latino depression and anxiety. Evidence is lacking regarding the overall effectiveness and generalizability of these adapted interventions. This study conducted a systematic review and meta-analysis of psychotherapeutic interventions for Latino depression or anxiety.

Method:

A search of nine electronic databases and manual review of reference lists were conducted. Thirteen studies of randomized controlled trials were eligible and included for meta-analysis using robust variance estimation in meta-regression.

Results:

An overall small treatment effect that is statistically significant was identified for Latino depression or anxiety of d = 0.334, 95% confidence interval [0.049, 0.619], p < .05.

Discussion and Implications:

More research is needed to determine the effectiveness of culturally adapted psychotherapeutic interventions for Latino depression or anxiety.

Keywords

Latino psychotherapeutic interventions Latino depression or anxiety systematic review meta-analysis

Anxiety and depression, affecting all demographics across the life span, are the two most common mental health disorders for the population in the United States, with anxiety disorders estimated at 28.8% (Kessler et al., 2005) and depression estimated at 17% (Centers for Disease Control and Prevention [CDC], 2018). An estimated 7.1% of children and teenagers (CDC, 2019) and 21.7% of adults (Kessler et al., 2005) in the United States have an anxiety disorder in their lifetime. One in six Americans, approximately 17%, will experience depression in their life span (CDC, 2019). The estimates of overall prevalence rates of depression among Latinos were higher than the national average of 17% at a rate of 27% determined by a cross-sectional analysis of 15,864 men and women aged 18–74 years in the population-based Hispanic Community Health Study/Study of Latinos (Wassertheil-Smoller et al., 2014). In this study, a shortened Center for Epidemiological Studies Depression Scale was used to assess depression (Wassertheil-Smoller et al., 2014). Alegria et al. (2008), found a rate of anxiety disorders for U.S.-born Latinos 18.9% compared to foreign-born Latino immigrants at a lower rate of 15.2% using data from the National Latino and Asian American Study and the National Comorbidity Survey Replication (Kessler & Merikangas, 2004). Although numbers vary depending on the study and method, it is still clear Latinos are experiencing anxiety and depression. We used Latino to refer to Hispanic and Latino population studied in this research. The term “Hispanic” emerged in the middle to late 1970s and was used by the Census Bureau in the 1980s to describe people with varying backgrounds but share a common language and cultural heritage (Del Olmo, 2001 as cited by Delgado, 2007). The term Latino emerged in the early 1990s and it is not uncommon to see the terms Hispanic and Latino used interchangeably (Delgado, 2007).

The Latino population in the United States was 56.5 million in 2015 accounting for 17.6% of the total population, and it is expected to grow to 29% of the population by 2050 (Pew Research, 2015).The high prevalence of both depression and anxiety among Latinos and the limited number of culturally adaptive interventions and research of efficacy create the need for research to identify if culturally adaptive interventions are effective in addressing depression and/or anxiety among Latinos. Without effective treatment for Hispanics with anxiety and depression, the negative societal effects will compound as the percentage of the population grows likely leading to more economic, health, and familial costs to individuals and society.

This study reports findings of a systematic review and meta-analysis of culturally adapted psychotherapeutic interventions for treating Latino depression or anxiety. The purpose of this study is to evaluate whether culturally adapted psychotherapeutic interventions are effective for treating Latino depression or anxiety. Studies included had interventions for treating depression or anxiety because depression and anxiety are highly comorbid, and both outcomes are often reported simultaneously in clinical trials.

Compared with non-Latino Whites, Latinos with similar mental health needs are using mental health services less due to cultural, structural, and economic factors (Cabassa et al., 2006). Other barriers to receiving the care they need are lack of Latino health-care professionals, low socioeconomic levels, higher rates of uninsured, and societal and individual prejudices and discrimination (Ruiz, 2002). If mental illness is left untreated, it negatively impacts daily functioning causing poor concentration (Aisenberg et al., 2012), lack of energy (Alegria et al., 2008), can result in a poorer response to future treatments, and a higher risk the mental illness will become chronic (Ghio et al., 2013).

Despite the critical need for services, research continues to identify mental health service gaps among Latinos and suggests that the use of nonculturally sensitive interventions may not be effective for Latino populations. The use of culturally adapted interventions may be a solution for encouraging adherence and retention to mental health services for Latinos.

Cultural match theory states individuals benefit from interventions that align more closely with their cultural characteristics (La Roche et al., 2011). La Roche et al. tested this theory with the Latino population and found patients were more likely to adhere to a culturally competent relaxation intervention that aligned with their cultural values of allocentrism, a term used to describe a personality trait in which a person focuses their attention on others’ actions more than themselves. Specifically, for depression, a culturally adapted behavioral activation technique showed preliminary success in Latino engagement and continued investment in services (Kanter et al., 2010). In recent years as the importance of culturally competent treatment modalities emerged, conceptual models and frameworks for implementing cultural adaptations have been created and implemented with the realization of the complexity of this process. Bernal et al. (2009) highlighted the different views of treatments, one view stating universal treatments should be able to apply to all people, while others called for a completely separate approach to interventions depending on the culture (Comas-Diaz, 2006). As a middle ground between the above approaches, culturally adapted evidence-based treatments show positive results with diverse populations such as Latinos and Asian Americans. However, efficacy is inconclusive due to the various ways of measuring cultural adaptations. For behavioral health interventions, there has been enough literature published on steps to take to culturally adapt interventions that five common stages have emerged that behavioral health researchers and practitioners can use when determining when and how to implement adaptations (Barrera et al., 2013). All of the above frameworks give great guidance on how to identify the need and implement cultural adaptations. A comprehensive review article (Jani et al., 2009) looking at the effect of cultural adaptations of interventions used in the areas of health, mental health, and substance abuse with Latinos found that most of the 23 studies included showed positive outcomes after implementing a culturally adapted intervention. The groundwork has been laid, but more research is needed to synthesize the evidence and examine the effect size of culturally adapted interventions on client outcomes.

Limited systematic reviews attempted to conclude the effectiveness of the statistical significance compared to treatment. One systematic review study (Pineros-Leano et al., 2017) examined 11 randomized controlled trial (RCT) and non-RCT studies to determine the effectiveness of cognitive behavioral therapy (CBT) with immigrant Latinos and described the various cultural adaptations. Pineros-Leano et al. concluded that the CBT interventions resulted in decreased depression symptoms. They described the cultural adaptations used in the various studies such as environmental and cognitive adaptations but were not able to measure how effective these were. Another systematic review of 36 RCT and non-RCT studies focused on depression treatment among Latino adults (Collado et al., 2016). Thirty-five of the studies incorporated cultural modifications to the interventions, with the most common adaptation being the provision of therapy in Spanish. CBT delivered in client’s homes or via teletherapy showed significant reductions in depression compared to control participants. Individual outcomes had the best results when using interpersonal treatment for 16 sessions. The study called for a more thorough evaluation of treatment moderators relevant to Latinos, including language preference, acculturation, and subsequent case management given the heterogeneity of the population. With the results of the above studies, it remains unclear how effective cultural adaption is for this population and what components are responsible for this effect if there is a significant one.

Even fewer meta-analyses examined the effect of culturally adapted interventions, without a focus solely on Latinos. A meta-analysis by Escobar and Gorey (2018) sought to determine whether culturally adapted cognitive behavioral interventions (CBIs) have a different effectiveness than those without adaptation. They determined the effect to be significant at postintervention period, d = 0.41, 95% confidence interval (CI) [0.30, 0.52], and at 6- to 12-month follow-up with d = 0.44, 95% CI [0.30, 0.58] when compared to interventions that were not adapted or were only adapted on “surface structure,” which involved matching the intervention to observable characteristics of the population (e.g., language) but did not include deeper cultural aspects. The authors suggested the continued need for research due to small sample sizes and the RCTs being more randomized pilot trials that lacked blinding. Another meta-analysis (Van Loon et al., 2013) looked at the effectiveness of culturally adapted depression and anxiety treatments for ethnic minorities in Western countries and found a significant pooled effect size of 1.06, 95% CI [0.51, 1.62], p < .001. They contributed the effectiveness to the adaptations on cultural values and beliefs related to the healing process. Of the nine studies used for Van Loon et al.’s review, only three focused specifically on the Latino population showing the knowledge gap of the effectiveness specifically for Latinos.

As evidenced by the above literature, no meta-analyses have focused on culturally adapted interventions using RCTs to treat anxiety or depression among Latinos. While culturally adapted intervention research for Latinos tends to grow, research is needed to determine whether and how culturally adapted interventions are working and which conditions among Latinos yield the most effectiveness. In addition, conclusions taken from previous studies that lacked the rigor of RCTs may be producing biased results. Therefore, this study will add to the growing knowledge base in an important way.

Method

Following the Cochrane Collaboration Guidelines (Higgins & Green, 2011), this study used various search strategies to obtain relevant literature published between 1900 and February 2019. The strategies included searching nine electronic databases, grey literature, and reference lists in related systematic reviews. The nine electronic databases were CINAHL Plus with Full Text, Family & Society Studies Worldwide, Gender Studies Database, Social Sciences Full Text (H.W. Wilson), Education Resources Information Center, Academic Search Complete, Health Source: Nursing/Academic Edition, Psychology and Behavioral Sciences Collection under EBSCOhost, and Scopus. These databases were included as they covered a wide range of journals related to mental health and the topic of interest to this review. The initial eight databases were searched using the search terms to identify culturally adapted (“culturally adapted” or “culturally competent” or “culturally sensitive”) AND Latino population (latin*) AND therapy (therap*) AND depression (depress*). Choosing only peer-reviewed articles with these terms yielded only 35 results. The search was then expanded by using the search terms to identify culturally adapted (cultur*) AND Latino population (latin*) AND therapy (therap*) AND (depress*) OR anxiety (anx*), which yielded 170 results. The same broader terms were then used in Scopus, which added 126 results. After input from the reviewer, we did post hoc analyses using the term Hispanic and resulted in an additional four studies.

Inclusion and Exclusion Criteria

To be eligible for inclusion, a study needed to be (1) an RCT that took place in the United States and (2) examining the effects of psychotherapeutic intervention on depression and/or anxiety of Latinos. Study participants could be of any age as long as they were Latino. Psychotherapeutic interventions are broadly defined in this review to include therapeutic techniques or strategies used by therapists and psychosocial interventions implemented by community health practitioners with the intent to improve mental health symptoms. Community health practitioners are persons with knowledge about the community they work in and are providing support, services, or psychosocial interventions with the desire to create positive change in the community. Community health workers such as promotoras referring to community health workers in Spanish-speaking communities are also included in this category (Office of Minority Health & Health Equity, 2019). Latinos were operationalized as a person of any age belonging or relating to a culture from Latin America or other countries that speak Spanish/and or English and define themselves as Latinx. Culturally adapted was defined as any item of the intervention modified to be sensitive to the culture of individuals who are receiving the treatment that takes into account their values, language, rituals, social networks, background, and “lived experience of the participants” (Marsiglia & Booth, 2015). Culturally adapted interventions for Latinos may include but are not limited to including the following features: program delivered in Spanish, use of Latino community health workers “promotora,” and addressing mental health beliefs and norms specific to Latino community. A study was included if it used measure(s) of depression and/or anxiety as either primary or secondary outcomes. For example, a study that examined the effect of a culturally sensitive cognitive behavioral group intervention for Latino Alzheimer’s caregivers and measured neuropsychiatric symptoms as well as depression would be included. Studies were only accepted if published in English. A study would be excluded if (1) Latinos were not a part of the intervention, (2) did not have a randomly assigned control/comparison group, (3) did not contain measure(s) of depression and/or anxiety, (4) did not report necessary statistical information for effect size calculations, (5) did not include a cultural adaptation to the intervention, and (6) was conducted in another country.

Screening and Data Extraction

Two doctoral-level students and one postdoctoral fellow participated in eligibility screening, and the two doctoral students completed the data extraction procedures. Using Covidence online software (https://www.covidence.org/home), title and abstract of each study was screened by each doctoral student independently and blinded to each other’s decisions. The third independent screener (postdoc fellow) resolved the conflicts. During full-text screening, the two doctoral students independently reviewed the full texts and discussed any differences. The independent reviewer was consulted on the articles that the students could not find a consensus. A manual review was conducted of the reference lists of systematic reviews related to interventions for Latinos for depression or anxiety to identify any missed studies from the search for inclusion. A coding sheet for data extraction was developed and then used to guide coding of all included studies.

Coding domains (available upon reasonable request from the first author) consisted of participant and provider characteristics, intervention characteristics, research design, and effect size data. Participant characteristics included age, gender, marital status, socioeconomic status, and Latino subgroup. Provider characteristics included profession, educational background, clinical experience, and whether they received supervision and training. Intervention characteristics included an intervention’s type (e.g., therapeutic vs. supportive), dosage (minutes per session, number of sessions, and duration in weeks), format (e.g., individual, group), delivery methods (e.g., in-person, technology-assisted), and delivery setting (e.g., home, community-based mental health service). Research design included the nature of the control group, diagnostic tools, and outcome measure(s). Since all studies included were RCTs, the nature of the comparison group was coded as treatment as usual or waitlist control.

Interscreener and Interrater Agreement

Satisfactory interscreener reliability was observed with 79% for title/abstract and 85% for full-text screening. Interrater reliability was calculated using a percent agreement model by dividing the number of agreements over all possible extractable data points. The two researchers reached a satisfactory interrater agreement of 87% for data extraction. All disagreements were resolved by discussion and consensus.

Data Analysis

Data extraction was conducted in Microsoft Excel and analyzed using R software (version 1.1.463) in four stages: (1) conducting descriptive statistics of participants, providers, intervention characteristics, and research design; (2) calculating small sample–corrected effect size estimates; (3) synthesizing effect size estimates across studies; and (4) moderator analysis using meta-regression.

Effect Size Calculation

All of the depression and anxiety outcomes reported in the studies for this analysis were continuous outcomes. Therefore, their effect size estimates were calculated using Hedges’ g effect size (Cooper et al., 2009). Hedges’ g represents standardized mean differences when different measures were used across studies. The g value was further adjusted using Hedges’ small sample size correction (Hedges, 1981) to obtain an unbiased estimate. This estimate is noted as “d” in this review.

Effect Size Synthesis and Moderator Analysis

An overall treatment effect size estimate and moderator analyses were conducted using robust variance estimation (RVE) in meta-regression, a method that has been supported by both methodological and previous empirical studies (Hedges et al., 2010; Tanner-Smith & Tipton, 2014; Zhang et al., 2019). Several studies included in this review reported multiple effect sizes, which introduced statistical dependence into the resulting effect sizes. Comparing with other statistical procedures that handle within-study dependence, such as generalized least squares estimation (Olkin & Gleser, 2009) or multilevel meta-analysis modeling (Van den Noortgate et al., 2013), RVE fits better because RVE makes no assumptions about effect size sampling distributions and can estimate the covariance structure of the dependent effect sizes without statistical information needed in other methods. Methodological studies recommended an ideal sample size of five effect sizes per study and 40 studies for RVE to generate reasonably accurate results (Hedges et al., 2010; Tipton, 2015). Because existing studies meeting the inclusion criteria of this study is less than 40, we used small sample size adjustment when running the meta-regression with RVE (Tipton, 2015).

Having identified variability among effect size estimates, we conducted moderator analyses to examine factors that influence effect size. Moderator analysis is able to indicate the statistical differences between different subgroups. Since it does not determine if the effect size of each subgroup is statistically significant, an analysis of treatment effect among subgroups is conducted alongside moderator analysis to improve the results of clinical significance.

Publication Bias and Risk of Bias

Publication bias refers to the nonrepresentativeness of articles published among all the research done in an area. This happens when studies with nonsignificant results are less likely to be published, which affects the bias of effect sizes. This review used Vevea and Woods’ (2005) weight function model to statistically assess the possibility of publication bias, and a funnel plot of the effect size estimates graphed against their standard errors was used to visually depict the bias. Risk of bias was assessed in light of the evaluation criteria specified in the Cochrane Handbook for Systematic Reviews of Intervention (Higgins & Green, 2011).

Results

Search Results

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram in Figure 1 shows the results of a detailed literature search and the results from the selection process. A total of 331 references were uploaded to Covidence for screening, 98 duplicates were removed leaving 233 for title and abstract screening. Of the 233 articles, only 26 articles met inclusion criteria for full-text screening. Full-text review further excluded 16 due to research design leaving 10 studies for data extraction. A manual review was conducted of the reference lists of systematic reviews related to interventions for Latinos for depression or anxiety, and 8 more studies were identified for potential inclusion but then 3 were excluded due to research design leaving 15 studies for data extraction. The five studies that had been found had been missed in the original search due to not including search terms of Hispanic and subgroups such as Mexican. During data extraction, one study was further excluded due to missing a control group and another as the intervention measured was not psychotherapeutic, resulting in final 13 studies selected in the meta-analysis.

Figure 1.

PRISMA diagram of search flow.

Study Characteristics

Table 1 presents study characteristics of all 13 studies, with a total sample size of N = 1,532 participants included in this review. Nine studies (64%) examined depression as the primary outcome and one study examined anxiety as the primary outcome. The remaining three studies examined both anxiety and depression outcomes. Participants were an average of 41 years old. Three studies did not provide relationship status, but of the 10 that reported about half were partnered (47%), and 83.7% were female. All 13 studies used randomized control design. Most of the studies (85%) used therapeutic interventions, therapeutic and supportive (38.4%), two studies (22.2%) used supportive only, and one study used mixed interventions. Four studies (30.7%) used active treatment control groups, only one used waitlist as a control group, and eight studies (61.5%) used treatment as usual. A large variety of Latino subgroups were identified including Mexican American, Puerto Rican, Dominican Republic, Columbian, Guatemalan, Central and South American, and two identifying the population as only Latino and not breaking them into subgroups. Not all studies commented on socioeconomic status, but six articles reported income ranging from US$10,000 to US$50,000 average annual income of participants; two articles denoted employment status only with no income denoted.

Table 1.

Descriptive Statistics of Articles in Meta-Analysis.

Author	Sample	LatinX Subgroup	Demographic	Control	Provider	Intervention Characteristics	Inclusion Criteria	Outcome Measures	Attrition Rates
Pina et al. (2012)	T = 29, C = 59	59.1% Hispanic, Mexican origin	10 years old, 51.1% female	TAU	Seven doctoral students supervised by licensed psychologist provided sessions	12 weeks, 60-min sessions, child-only condition mother involved last 10 min, child plus parent condition parent present the entire session	ADIS-C/P	ADIS-CSR, ADIS-C, ADIS-P, RCMAS, CDI	Preliminary analysis showed no attrition bias—NR post-study
Hinton et al. (2011)	T = 12, C = 12	Dominican, Puerto Rican	50 years old, 100% female, eighth-grade average education	ATC	Therapy in groups by LCSW and psychiatrist	Weekly 1-hr sessions for 14 weeks culturally adapted CBT compared to muscle relaxation	DSM-IV	Nervios Scale, SCL-Anxiety Scale	NR
Ashing and Rosales (2014)	T = 110, C = 111	Birth country 26% United States, 74% other	53 years old, 100% female, 59% married	TAU	Two bilingual paraprofessional interventionists > 2 years college ed, >3 years experience	Eight 40–50 min biweekly psychoeducational telephone sessions	CES-D (FACT)-Breast	CES-D	10%
Marcus et al. (2016)	T = 104, C = 101	84.4% Mexican, Dominican Republic, Puerto Rican, Columbian, and Guatemalan	39 years old, 100% female, 53.7 married	ATC	PhD level researcher conducted culturally and linguistically adapted, Internet-based physical activity intervention	24 weeks intervention group received access to study website that included (1) self-monitoring of activity, (2) goal setting with graphs, (3) message board for social support, (4) “ask expert” PhD researcher, and (5) online resources compared to the control group that received access to Spanish language website with information on health topics and physical activity.	CES-D	CES-D	NR
Gonyea et al. (2016)	T = 33, C = 34	84.4% Mexican, Dominican, Puerto Rican, and Columbian	55 years old, 92.7 female, 40.3% married	WLC	Bilingual Masters Social Worker used culturally sensitive framework that was consistent of values, beliefs, and lived experiences in all phases of the research project	12 weeks, 90-min sessions per the participants request all sessions were done in Spanish. The treatment group received CBT intervention. The control group received psychoeducation services by telephone. Services received at a community-based mental health setting.	CES-D measured by a Spanish version. STAI-S measured by a Spanish version	CES-D, STAI-S	T-4 did not complete, C-6 did not complete
Simoni et al. (2013)	T = 20, C = 20	Mexican American	46 years old, 72.5% male, 27.5% female, 65 single and 35 married	TAU	Five bilingual–bicultural Latino graduate students in psychology. Two had master’s degrees and two enrolled in an MA program in clinical psychology that used culturally adapted CBT. The intervention was done at a community clinic.	16 weeks, 50-min sessions. The individual CBT treatment was for adherence and depression with an alarmed pillbox compared to usual care. Intervention was done in English and Spanish.	BDI, MADRS	BDI, MADRS	20% lost to follow-up
Le et al. (2011)	T = 94, C = 92	Central American and South American	25 years old, 100% female, 35.9% single, and 64.9% married	TAU	Two post bachelor’s bilingual bicultural research staff conduct CBT psychoeducational group sessions. A cultural adaptation was utilized. Conducted in a community-based health center and a hospital clinic	8 weeks, 120-min sessions. The CBT course was taught in Spanish.	CES-D, BDI-II, and MDE	CES-D, BDI-II, and MDE	30% lost to follow-up
Gallagher- Thompson et al. (2008)	T = 47, C = 42	Hispanic/Latina	52 years old, 100% female, 77.5% single, and 18% married	ATC	Interventions were conducted by postdoctoral fellows or advanced graduate students in psychology or related fields that used bilingual and bicultural frameworks. Small groups occurred at a community center.	16 weeks, 120 min CBT small group compared to minimal telephone-based group	CESD	CESD	16%, with no significant differences by condition or by ethnicity
Bedoya et al. (2014)	T = 63, C = 55	Latino/Hispanic	42 years old, 69% female, 42% married, and 58% unmarried	TAU	Interventions were conducted by clinicians that were supervised weekly.	First visit was 90 min and second visit was 45 min conducted in Spanish	DSM-IV	PHQ-2	lost 15% in 6 months
Ell et al. (2017)	T = 178, C = 170	Latino, Mexican 68%, and Central American 16%	57 years old, 85% female, did not complete high school 79%	TAU	Sessions by promotora that was trained and supervised	T received 6 weekly psychoeducational sessions followed by three booster sessions compared to usual clinic care to evaluate depression and self-care management for diabetes and heart disease patients	PHQ-9	PHQ-9	Study attrition at 12 months was 30% (AHH 31% vs. UC 28%, p = .51) 104 patients lost to follow-up
Beeber et al. (2010)	T = 34, C = 37	Latina mothers, Mexican 92%	26 mean age, less than 10 years of education, 84% with partner, preferred Spanish	TAU	Culturally tailored intervention delivered by master’s level psychiatric nurses and project trained Spanish language interpreters	T received 11 in home psychotherapy intervention interspersed with five short booster visits with only interpreter, 16 contacts, mothers completed questionnaires and 45-min videotaping of interaction with child	CES-D	CES-D	13%
Kanter et al. (2015)	T = 21, C = 22	Mexican, Puerto Rico, and other	38 years old, 79% female, and 53.5% married	TAU	Existing MH practitioners were TAU one of the four had clinical practice licensure while one was obtaining licensure	12 weeks of session, weekly for 50 min	DSM-IV	Hamilton Rating Scale for depression (HRSD)	Posttreatment 34.9%, follow-up 41.9%
Feldman et al. (2016)	T = 16, C = 16	Latino, Puerto Rican 83%	43 years old, 94% female, married 23%, 27% high school education or less, and 50% income less than 16K	ATC	Clinical psychology postdoctoral fellow and advanced graduate students, given training and supervision	T-CBPT compared to music and relaxation therapy, 8 weekly sessions	DSM-IV criteria for PD, PDSS > 8	PDSS	0% at 3-month follow-up

Note. Measurement scales = ADIS-C: Anxiety Disorders Interview Schedule—Child Symptom Count; ADIS-C/P = Anxiety Disorders Interview Schedule for DSM-IV—Child and Parent Versions; ADIS-CSR = Anxiety Disorders Interview Schedule—Clinician’s Severity Rating; ADIS-P = Anxiety Disorders Interview Schedule—Parent Symptom Count about the Child; BDI = Beck Depression Inventory; CBT = cognitive behavioral therapy; CDI = Children’s Depression Inventory; CES-D = Center for Epidemiological Studies Depression Scale; DSM-V = Diagnostic and Statistical Manual of Mental Disorders, fifth edition. CBPT = cognitive behavior psychophysiological therapy; (FACT)-Breast = Functional Assessment of Cancer Therapy; MADRS: Montgomery–Asberg Depression Rating Scale; MDE = Major Depressive Screener/mood screener; RCMAS = Revised Children’s Manifest Anxiety Scale; S-BDI = Spanish-Language Beck Depression Inventory; STAI-S = State Anxiety Inventory-State; PDSS = Panic Disorder Severity Scale. T = treatment group sample size; C = control group sample size; NR = not reported; TAU = treatment-as-usual (as defined in the text); WLC = Waitlist control; ATC = active treatment control; LCSW = Licensed Clinical Social Workers.

Seven studies (54%) used individual intervention, four (44.4%) used a group intervention, and two used both individual and family interventions. Most studies (85%) used in-person interventions, one study used technology-assisted interventions, and one study used a telephonic method. Five interventions (n = 5, 38.4%) were delivered at community-based mental health centers, and two were at outpatient clinics (15.3%).

Thirteen studies reported an average of 12 sessions for the intervention, ranging from 5 to 24 sessions. Ten studies reported an average of 65 min per session, ranging from 15 to 120 min. Of the three remaining studies, in one, participants got to choose how many minutes they engaged with the intervention and results were not provided; the remaining two studies’ information on minutes was not included. All studies together reported an average of 11.6 weeks of intervention duration, ranging from 4 to 24 weeks across different interventions.

Interventions were implemented by mental health professionals in 69.2% of the studies and three (23%) used paraprofessionals only with one using paraprofessional and medical personal and one of the studies that used mental health professionals also used medical personnel. Seven of the studies had providers with master’s degrees or higher implementing the intervention (54%). Providers were given training before and supervision while implementing the interventions in 12 studies, and one did not provide this information.

Publication Bias and Risk of Bias

Publication bias was assessed using funnel plot (Figure 2) by plotting observed effect size estimates by their standard errors. The distribution of effect size estimates was reasonably symmetric with many of the values falling within the funnel, which supported the absence of publication bias. Vevea and Woods’ (2005) sensitivity analysis further supported this conclusion with the observed effect size (solid vertical line) overlapping with a theoretical effect size (solid vertical line on center) for the funnel to be theoretically symmetric.

Figure 2.

Publication bias assessing using funnel plot and sensitivity analysis.

Table 2 presents the results of assessing risk of bias. Overall, studies reported low risk of bias in random sequence generation (13/13), allocation concealment (11/13), selective reporting (9/13), and blinding of personnel and participants (9/13). Studies, however, reported high risk of bias in handling incomplete outcome data (8/13) and blinding of outcome data (5/13).

Table 2.

Cochrane Collaboration’s Tool for Assessing Risk of Bias.

Study	RSG	AC	BPP	BOD	IOD	SR
Pina et al. (2012)	+	+	−	?	+	+
Feldman et al. (2016)	+	?	+	?	−	?
Hinton et al. (2011)	+	−	?	−	+	?
Ashing and Rosales (2014)	+	+	+	+	?	?
Marcus et al. (2016)	+	+	−	?	?	+
Gonyea et al. (2016)	+	+	−	?	+	+
Simoni et al. (2013)	+	+	+	?	?	?
Gallagher-Thompson et al. (2008)	+	+	+	+	?	+
Kanter et al. (2010)	+	+	+	+	+	+
Beeber et al. (2010)	+	+	+	?	+	+
Bedoya et al. (2014)	+	+	+	+	+	+
Ell et al. (2017)	+	+	+	?	+	+
Le et al. (2011)	+	+	+	+	+	+
Total number of “+”s	13	11	9	5	8	9

Note. RSG = random sequence generation; AC = allocation concealment; BPP = blinding of participants and personnel; BOD = blinding of outcome data; IOD = incomplete outcome data; SR = selective reporting. “+” = low risk of bias; “−” = high risk of bias; and “?” = unclear risk of bias.

Meta-Analytic Results

The overall treatment effect was estimated using an intercept only meta-regression analysis with RVE and small sample size adjustment. The 13 RCTs contained 44 effect sizes. An overall minor treatment effect that is statistically significant was identified for Latino depression or anxiety, d = 0.334, 95% CI [0.049, 0.619], p < .05. On average, participants receiving culturally adjusted psychosocial services reported 0.334 standard deviations (SDs) higher than participants in the comparison/control group.

Moderator and Subgroup Analysis

Table 3 presents the results of the moderator and subgroup analyses. Age, gender, comparison group type, number of sessions, minutes per session, and duration of weeks of intervention, and profession of provider did not show any significant moderated treatment effect. Marital status significantly moderated treatment effect, b = 0.002, 95% CI [−0.020, 0.025], p = .025. For participants who are not married, treatment effect was 0.002 SDs higher on average than those who were married. In addition, subgroup analysis of depression and anxiety did not result in any significant outcomes among subgroups. Univariate meta-regression indicated that outcome type (depression = 1 and anxiety = 2) did not significantly moderate the treatment effect, b = 0.955, 95% CI [−0.347, 2.258], p = .101, indicating the difference in effect size between depressive and anxiety outcomes was not statistically significant. There were no subgroup effects with only one moderated effect for those that were not married, b = 0.002, 95% CI [−0.020, 0.025], p = .025.

Table 3.

Overall Treatment Effect and Single-Predictor Meta-Regression Analysis.^a,b

Characteristics/Moderators	Estimate	t (df)	K/N	95% CI	p
Overall treatment effect	0.334	2.57 (11.5)	13/43	[0.049, 0.619]	<.05
Outcome type (ref: depression, b ₀)	−0.657	−1.87 (6.29)	13/43	[−1.507, 0.192]	.108
Anxiety (b ₁)	0.955	2.37 (2.91)	13/43	[−0.347, 2.258]	.101
Age (b ₀)	1.720	2.22 (1.6)	13/43	[−2.544, 5.983]	.187
(b ₁)	−0.033	−1.90 (2.9)	13/43	[−0.088, 0.023]	.156
% Female (b ₀)	2.773	1.91 (1.76)	13/43	[−4.365, 9.911]	.213
(b ₁)	−0.0312	−1.72 (2.61)	13/43	[−0.081, 0.027]	.197
% Married (b ₀)	0.067	0.180 (4.40)	9/26	[−0.925, 1.058]	.865
(b ₁)	0.002	0.311 (3.27)	9/26	[−0.020, 0.025]	.025
Control group (ref: active control, b ₀)	2.033	2.11 (4.28)	13/43	[−0.579, 4.645]	.098
Nonactive control^c (b ₁)	−0.944	−1.93 (6.84)	13/43	[−2.108, 0.219]	.096
Minutes per session (b ₀)	0.966	1.47 (3.76)	9/35	[−0.907, 2.840]	.220
(b ₁)	−0.006	−1.05 (2.72)	9/35	[−0.024, 0.013]	.378
Number of sessions (b ₀)	−0.2424	−0.329 (2.80)	9/32	[−2.683, −0.182]	.765
(b ₁)	0.0784	0.892 (3.44)	9/32	[−0.182, 0.339]	.431
Duration (b ₀)	0.392	0.746 (5.55)	13/43	[−0.920, 1.705]	.508
(b ₁)	0.018	0.441 (5.55)	13/43	[−0.082, 0.117]	.911
Intervention provider (ref: mental health, b ₀)	0.950	1.66 (6.05)	13/43	[−0.446, 2.347]	.147
Nonmental health providers (b ₁)	−0.198	−1.28 (4.20)	13/43	[−0.621, 0.225]	.268

Note. K = number of studies; N = number of effect sizes; df = degrees of freedom; CI = confidence interval. b ₀ should be interpreted as the intercept in a regression model, that is the value of the reference group or when the moderator value equals to zero, and b ₁ should be interpreted as the regression coefficient that is for each unit increases in the moderator or when the moderator equals to one, what is the associated increase in the dependent variable—effect size

^a If df < 4, a lower p value (p < .01) should be used for statistical inference.

^b Although presented in the same table, predictors were entered one-by-one individually to the model.

^c Nonactive control included (treatment-as-usual and supportive intervention).

*p < .05. **p < .01. ***p < .001.

Discussion and Applications to Practice

The population of the United States is evolving to have a higher concentration of Latinos, with lifetime estimates for anxiety, depression, and substance use disorders among Latinos in the United States at a prevalence of 28.1% for men and 30.2% for women (Alegria et al., 2008). The National Association for Mental Health documents common factors that impede Latinos from seeking mental health services, including cultural negative stigma, language barriers, lack of bilingual staff to help meet their needs, and lack of health insurance.

These high rates of depression and anxiety and barriers to service have led researchers and practitioners to develop and implement culturally adapted interventions to meet the diverse needs. However, there is limited research on the efficacy of culturally adapted interventions for Latino anxiety and depression. Thus, this study conducted a systematic review and meta-analysis of culturally adapted psychotherapeutic interventions for treating Latino depression and/or anxiety.

Overall, this study identified an overall minor treatment effect that is statistically significant of culturally adapted psychotherapeutic interventions for Latino depression and/or anxiety. There was not a significantly higher effect on those interventions treating anxiety over depression. Although our results offer promising evidence of the effectiveness of culturally adapted intervention for Latino depression and anxiety, the minor significance indicates these results should be taken as preliminary and support the need for continued research to support the claim. Here, we can relate to Hernandez Robles et al.’s (2018) and Valdez et al.’s (2018) findings that appeared to be close to our results although our significance was higher before we offer alternative explanations below. These two systematic reviews focusing on culturally adapted intervention for substance use rather than for anxiety and depression among Latinos showed small or no effects. Hernandez Robles et al.’s study found an effect size, d = 0.06 (p = .01), very small and not clinically important but did increase at a follow-up time point. They suggest that there may be secondary positive outcomes to culturally adapted interventions and that more research is needed to determine what makes these adaptations effective and with which subgroups of Latino populations. Similar to these nonclinically significant findings, the other systematic review (Valdez et al., 2018) analyzed the effectiveness of gender and cultural adaptations for alcohol and substance abuse interventions for Latino males and reported nonsignificant results. The studies reviewed by Valdez et al. had some mixed results showing positive results for secondary outcomes and some suggesting the culturally adapted interventions may outperform other treatments but were unable to determine if these results were related to the intervention, outcomes, or issues with methodology.

The result of a larger effect size across the studies for culturally adapted interventions for those that were not married may be explained by those that are married may be more likely to seek help from their family first or informal means before seeking treatment outside the family. Previous research suggests that Latinos that have family support are more likely to seek informal or religious means for mental health care (Villatoro et al., 2014). Therefore, when they seek help, their cases may be more severe, and therefore, the effectiveness of the culturally adapted intervention may not be as detected. More research would be needed to confirm this explanation or look into other differences and potential varying needs between these different groups.

This conclusion cautions firm interpretations from these results for several reasons. First, given the limited number of studies included, we may lack sufficient power to identify an overall greater significant effect size. The results of this study mirrored those from the only other meta-analysis identified that looked at culturally adapted interventions for Latinos (Escobar & Gorey, 2018) that found culturally adapted CBIs were more effective than CBIs without adaptation. The other study was able to show a higher significant effect because the study had a larger sample size and included non-RCTs. In light of these differences, more studies with a rigorous RCT design are warranted before reaching a definitive conclusion. Although it was necessary to have two outcome measures (i.e., measures of anxiety, depression) and a variety of different subgroups of the Latino population included due to the limited number of studies involving these populations, interpretations of our findings need to be cautious about the confounds due to such broad inclusion criteria.

Second, this study did not have sufficient information of the specific cultural adaptations of each study to be able to determine if certain kinds of cultural adaptations could have led to a higher significance in effect. More research is needed to determine culturally adapted components of interventions that may have an effect. Additional studies are needed to build upon these results and control for different variances in cultural adaptation. It may be that only a minor effect was found for cultural adaptations that are not grounded in the population, but more research would be needed to clarify this point. Cabassa and Baumann (2013) have suggested the need to combine cultural adaption models with implementation science in order to better understand not only how the adaptations may be affecting the microlevel of the client and practitioner but also to draw from the ecological perspective of implementation research to understand the context surrounding the intervention and how the context and adaptation interplay with one another. Future research could help expand these concepts by looking at not only the aspects of the interventions on a microlevel that are having an impact but also how the changes are interplaying with the organizational cultural and context surrounding the implementation of the cultural adaptation.

It is also necessary to conduct studies measuring the difference between effects in different Latino subgroups, as they have different levels of mental health concerns, cultures, and background that could affect the effect of interventions. For example, Wassertheil-Smoller and colleagues (2014) found that overall, the prevalence of depression was 27% for the Hispanic population, ranging from 22.3% for Mexican background to 38% for Puerto Ricans. These statistics highlight the risk of placing such a heterogenous population into one research category. Further interpretation caution is needed as this study only measured interventions that utilized depression and/or anxiety as an outcome. However, culturally adapted interventions for Latinos have been used to treat various other outcomes, and more studies are needed to see whether the intervention effect varies depending on the outcome measure. Additionally, mental health service providers reported significant challenges in providing evidence-based interventions that incorporate effective cultural adaptation to reach optimal treatment outcome (Antoniades et al., 2014). The challenges the practitioners face on the ground level may affect the fidelity of implementing the intervention, which in turn affects the effect. As researchers and practitioners continue to determine the best ways to serve the needs of Latinos, our findings shed important light on the importance of determining how to make culturally adapted interventions more effective for the Latino population.

This systematic review and meta-analysis revealed some limitations. To begin, it is important to note that there is a chance this review did not cover all of the studies. While the studies gathered by the Cochrane Library offered the basis for this meta-analysis, there is likely to be studies missing from both the Cochrane Library and the nine electronic databases. In turn, missing studies may affect the power of identifying a significant effect. In addition, data screening and extraction of data were run by two separate screeners/coders, which functioned independently of each other. Due to this factor, it is vital to note that human error will occur. Although it was necessary to have two outcome measures (i.e., measures of anxiety, depression) and a variety of different subgroups of the Latino population included due to the limited number of studies involving these populations, such broad inclusion criteria may introduce confounds in terms of maturity, instrumentation, and differential levels of acculturation may result in confounding variables. Last, this study was limited by its small sample size. Thus, the minor significance may simply be due to low statistical power.

This study represents the only meta-analysis to our knowledge that examined the effectiveness of culturally adapted interventions (not limited to a certain modality) for Latino depression or anxiety. Despite the limitations, this research has concluded that current research can support that culturally adapted psychotherapeutic intervention has a minor significant effect on depression or anxiety. More evidence is needed regarding the effect of culturally adapted psychotherapeutic interventions for Latino anxiety or depression, particularly related to what are the effective or ineffective aspects of these treatments, but social workers and those working with Latinos can use these results to have some confidence that cultural adaptions while working with diverse populations is having some effect. As the Latino population continues to rise, it is imperative that social workers, counselors, and other helping professionals determine the most effective and approachable interventions to serve this population, so that they are open to receive services and feel comfortable to return to healing environments.

Supplemental Material

Supplemental Material, PRISMA_2009_checklist - Culturally Adapted Psychotherapeutic Interventions for Latino Depression and Anxiety: A Meta-Analysis

Supplemental Material, PRISMA_2009_checklist for Culturally Adapted Psychotherapeutic Interventions for Latino Depression and Anxiety: A Meta-Analysis by Abbie Nelson, Esther Ayers, Fei Sun and Anao Zhang in Research on Social Work Practice

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Abbie Nelson

Anao Zhang

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