Bridging Disciplinary Boundaries (January 11 - 14, 2007)

Purpose: Depression is a common and disabling disorder among Latinos served in primary care settings. Few randomized clinical trials (RCT) testing the effectiveness of depression treatments have included adequate numbers of Latinos to evaluate the quality and outcomes of these treatments in this underserved population. This lack of empirical evidence poses a serious threat to the ecological validity of depression treatments and places Latinos at considerable risk for receiving inadequate depression care. A systematic review of recent published RCT examining depression treatments in primary care for Latino adults is used to address this gap in the literature. The aims of this review are (1) to evaluate the methodological quality, outcomes, and cost-effectiveness of depression treatments in primary care for Latino adults, and (2) to draw conclusions from this body of research for improving depression care among this diverse population. Methods: Electronic bibliographic databases, websites, and manual searches were used to identify relevant articles. Articles were chosen for review if they met the following criteria: (1) compared the effectiveness between of one or more depression treatments and usual care in primary health care settings, (2) randomized patients and/or clinics to treatment conditions; and (3) reported treatment effectiveness findings for Latinos. Two reviewers working independently evaluated studies' methodological characteristics using a modified version of the Methodological Quality Rating Scale. Findings: Nine peer-reviewed articles published from 2003 to 2006 covering 4 RCT were included in this review. Studies were rigorous trials of high methodological quality that used standardized treatment protocols, provided sufficient detail for replication, were able to follow-up on average more than three-fourths of their initial sample, enumerated drop-out rates, and used appropriate statistical analyses. All trials used manualized short-term psychotherapies (e.g., cognitive behavioral therapy, problem-solving therapy) and/or standardized medication management protocols based on treatment guidelines. Cultural and linguistic adaptations used in these trials included employing bilingual and bicultural clinicians (e.g., social workers, nurses), having educational and intervention materials available in English and Spanish, using manualized short-term psychotherapies developed for Spanish speaking populations, and staff cultural sensitivity training. Findings from these studies indicate that culturally and linguistically tailored depression treatment programs for Latinos delivered in primary care are significantly more effective than usual care in reducing depressive symptoms, improving functioning, and increasing accessibility to guideline congruent care among this population. Two studies also found that these treatment programs were more cost-effective than usual care even with the added costs of cultural and linguistic adaptations and supportive services (e.g., child care, transportation). Implications: The implementation of effective and sustainable depression treatments for Latinos in primary health care settings has been proposed as a strategy to reduce mental health care disparities. Trials included in this reviews generate strong evidence supporting the use of evidence-based treatments in primary care as an effective and cost-effective strategy to reduce the inequities Latino primary care patients face in the accessibility and quality of depression care. Areas for future research and intervention development with this diverse population will be discussed.