A Critical Review of Culturally Sensitive Treatments for ...

1 A Critical Review of Culturally Sensitive Treatments for Depression:Recommendations for Intervention and ResearchZornitsa Kalibatseva and Frederick T. L. LeongMichigan State UniversityRecent meta-analyses and reviews have showed that Culturally adapted mental health interventions aremore effective for racial and ethnic minorities than traditional unadapted psychotherapy. Despite theadvances in providing Culturally Sensitive mental health services, disparities among racial and ethnicminorities still exist. As a body of literature on Culturally Sensitive Treatments accumulates, there is a needto examine what makes a treatment for specific presenting problems Culturally Sensitive . This articlepresents a Critical Review of existing Culturally Sensitive Treatments for depression because it is one of themost common and debilitating mental disorders.

2 In particular, we examined what treatment modalitieswere used, what types of adaptations were implemented, and what populations were targeted. Theconceptual framework this Review uses to categorize existing Culturally Sensitive Treatments includes atop-down, a bottom-up, or an integrative approach. The Review reveals that the majority of culturallysensitive Treatments for depression employed an evidence-based bottom-up approach, which involvedgeneral and practical adaptations, such as translating materials or infusing specific cultural values. Moststudies used cognitive behavioral strategies and included Latinos and African Americans. Recommen-dations and future directions in interventions and research are discussed to decrease mental health caredisparities among ethnic : Culturally Sensitive treatment, Culturally adapted treatment, depression, racial/ethnicminorities, adaptation, therapyDepression is among the most debilitating disorders and largestcontributors to the world s global burden of disease (World HealthOrganization [WHO], 2008).

3 Therefore, it has been of paramountimportance to find effective psychosocial Treatments for depres-sion and examine what Treatments work for whom (Norcross &Wampold, 2011). Previous reviews of psychosocial treatmentswith ethnic minorities (Huey & Polo, 2008; Miranda et al., 2005)and meta-analyses (Benish, Quintana, & Wampold, 2011; Griner& Smith, 2006; Smith et al., 2011) have examined the overalleffectiveness of cultural adaptations in various Treatments targetingmultiple disorders. In particular, cultural adaptations appear to bemore effective than no treatment (d ), treatment as usual(d ) or unadapted psychotherapy (d ; Benish et al.,2011; Huey & Polo, 2008) and show moderately strong benefitfrom pre- to post- intervention (d ; Griner & Smith, 2006).As depression is one of the most prevalent and incapacitatingmental disorders and mental health professionals strive to provideadequate depression treatment to all patients, it is important toexamine in depth the Culturally Sensitive Treatments for depressionin the United the existing evidence-based Treatments (EBTs) in theUnited States are infused with Western norms, researchers need todetermine whether such Treatments are equally effective for otherpopulations ( , ethnic minorities or nationals of other countries)or whether new Culturally Sensitive Treatments are necessary (Ber-nal & Domenech Rodr guez, 2012; Gone, 2009).

4 In the last de-cade, several studies explored the development and implementa-tion of Culturally Sensitive Treatments (CSTs) for depression fordifferent ethnic groups. However, this growing body of literaturehas not been reviewed and analyzed. The goal of this article is toprovide a Critical Review of the literature on Culturally sensitivetreatments for depression and to establish what makes a depressiontreatment Culturally Sensitive , how effective such Treatments are,and what populations CSTs targeted. Conceptually, this reviewexamines the existing Culturally Sensitive Treatments using a top-down approach or surface adaptations, a bottom-up approach ordeep adaptations, and an integrative approach or a combination oftop-down and bottom-up approaches. In the final section, we offerrecommendations for future research and implementation of CSTsfor depression with the goal to reduce mental health disparitiesamong Culturally diverse entail the tailoring of psychotherapy to specific culturalcontexts (Hall, 2001, p.)

5 502). Bernal and Domenech Rodr guez(2012) examined cultural adaptations within the framework ofevidence-based practice. The authors discussed the relationshipbetween psychotherapy and culture, which can range from invis-ible or absent to inseparable or intertwined (Bernal &Domenech Rodr guez, 2012, p. 4). Multiple terms have been usedto describe the variability and gradation in the relationship be-tween culture and psychotherapy, such as Culturally adapted,anchored, appropriate, centered, competent, congruent, informed,relevant, responsive , and Sensitive (p. 4). For example, the termZornitsa Kalibatseva and Frederick T. L. Leong, Department of Psy-chology, Michigan State concerning this article should be addressed to ZornitsaKalibatseva at the Department of Psychology, 127B Psychology Building,Michigan State University, East Lansing, MI 48824-1116.

6 Services 2014 American Psychological Association2014, Vol. 11, No. 4, 433 4501541-1559/14/$ DOI: embeddedimplies the strongest relationship such thatpsychotherapy is considered an integral part of the context,whereasculturally adaptedsuggests systematic changes to theprotocol of an existing treatment in order to make features of thetreatment relevant to the culture of the target population. Morespecifically, cultural adaptation is any modification to anevidence-based treatment that involves changes in the approach toservice delivery, in the nature of therapeutic relationship, or incomponents of the treatment itself to accommodate the culturalbeliefs, attitudes, and behaviors of the target population (Whaley& Davis, 2007, pp. 570 571). The termculturally sensitiveis usedin this Review to indicate varying degrees of integration of culturein psychotherapy, which may range from Culturally embeddedpsychotherapy to one or two specific cultural adaptations, such aschanging the language or hiring bicultural , Race, Ethnicity, and Disparities in ServiceUtilization Among Ethnic MinoritiesIn the last two decades, there has been an increased awarenessof the influence of culture on psychopathology and psychotherapy(Leach & Aten, 2010; L pez & Guarnaccia, 2000).

7 Workingdefinitions of race, ethnicity, and culture are provided below asthese concepts are often used interchangeably (Betancourt & Lo-pez, 1993). Race refers to similar observable physical character-istics, such as skin color, hair type and color, eye color, and facialfeatures. It often implies biological variation as the physiognomicfeatures specific to one race are associated with populations withinisolated geographic locations (Betancourt & Lopez, 1993). Ethnic-ity usually refers to groups that share characteristics, such asnationality, language, history, traditions, race, and/or culture. Typ-ically, ethnic characteristics occur simultaneously with race andculture, which may contribute to the common interchangeable useof these refers to highly variable systems of meanings, whichare learned and shared by a people or an identifiable segment of apopulation (p.)

8 630; Betancourt & Lopez, 1993; Rohner, 1984).Psychologically relevant elements that constitute culture represent social norms, roles, beliefs, and values (Betancourt ) and may include topics, such as familial roles, gender roles,communication styles, affective styles, values of authority or per-sonal control, individualism, collectivism, and spirituality amongothers (Betancourt & Lopez). These Culturally relevant elementsmay influence how people report and conceptualize their experi-ence of distress, determine if they seek and/or stay in treatment aswell as their treatment outcome ( Department of Health andHuman Services [DHHS], 2001).Data from the Collaborative Psychiatric Epidemiology Surveysrevealed that lifetime prevalence rates of depression among and ethnic groups varied.

9 Approximately of Hispan-ics, of Native Americans, of non-Hispanic Blacks, of non-Hispanic Whites, and of Asian Americans metcriteria for major depressive episode (Beals et al., 2005; Breslau etal., 2006; Takeuchi, Hong, Gile, & Alegr a, 2007). Researchershave found significant disparities in depression treatment amongethnic minorities in the United States despite the similar or lowerprevalence rates of depression compared to non-Hispanic Whites(Alegr a et al., 2008; Harman, Edlund, & Fortney, 2004). In anationally representative sample, Alegr a et al. (2008) identifiedsignificant ethnic differences in utilization of mental health ser-vices among people diagnosed with past-year depressive disorder,with of Latinos, of Asians, and of non-Hispanic Blacks, compared with of non-Hispanic Whites,failing to access services.

10 Moreover, there were disparities in thelikelihood of both having access to and receiving adequate care fordepression for Asian Americans and non-Hispanic Blacks in con-trast to non-Hispanic Whites. These findings are consistent withthe disparities in service utilization reported in the supplement tothe Surgeon General ReportMental health: Culture, race,and ethnicity( DHHS, 2001). The supplement provided anoverview of the limited mental health research with ethnic minor-ities and described the lack of information as a Critical disparity (p. 159, DHHS, 2001).Evidence-Based Treatments and Culturally SensitiveTreatmentsThe recognition of mental health service utilization disparitiesand the scarcity of research on psychological Treatments withethnic and racial minority populations necessitated the carefulexamination of all available information in this field.