Telephone Cognitive Behavioral Therapy for Rural Latinos: A Randomized Pilot Study

Background and Purpose: Latinos experience significant barriers in accessing and utilizing treatment for depression, including family, work, acculturative, economic, and migration-related stress as well as the lack of psychotherapy and evidence base mental health practices in primary care settings (Aisenberg et al., in press; Hovey et al., 2000; Magana et al., 2003; Vega et al., 1999). For Latinos residing in rural communities, the lack of bilingual and bicultural mental health providers and lack of specialty mental health services, geographic isolation, lack of transportation, and language/cultural barriers further contribute to the prevalence of disparities in depression care.

This paper examines the efficacy of a randomized clinical trial testing a culturally adapted, manualized telephone cognitive behavioral therapy (CBT) intervention for depression among rural Latino patients in a primary care setting.

Methods: This pilot study was conducted in partnership with the Yakima Valley Farm Workers' Clinic, a multi-service behavioral and physical health care organization consisting of 17 sites serving predominantly low-income Latino patients in rural Eastern Washington and northern Oregon. 101 Latino men and women who were identified through systematic screening as having major depression participated in the study. 50 patients were randomized to the CBT intervention which consisted of 8 sessions provided by trained MSWs. The remaining 51 patients were assigned to usual care (UC). 11 enrolled in each randomized status for a total N=22 (21.8%). 91% of all participants were born in Mexico and 79% of the total sample had received less than 11 years of formal education.

Depression outcomes were measured via the 20-item Symptom Checklist (SCL-20) (Derogatis & Melisaratos, 1983) and the Patient Health Questionnaire 9 (PHQ-9) (Spitzer et al., 1999) at baseline, and at 6 weeks, 3 month and 6 month post-baseline intervals. Group differences in depression outcomes were examined via a repeated measures linear mixed effects model where intervention group and wave were treated as fixed effects.

Results: The mean baseline score for both groups as measured by the SCL-20 was 1.8 (SD=0.8), indicating moderate depression. Using the PHQ-9, the mean baseline score for the intervention group was 16.7 (SD =3.7) and 17.67 (SD=3.3) for UC group. A cutoff score of 10 or above indicates moderate depression. At 3 months post-baseline, PHQ-9 scores were significantly lower for invention participants: 7.3 (SD=5.4) compared to 10.4 (SD=7.0) for UC participants (t= 2.09; p=0.040). Similarly, significant lower SCL-20 scores were reported at the 3-month assessment point: 0.9 (SD=0.7) for intervention participants compared to 1.3 (SD=0.8) for UC participants (t=2.26; p=0.027). At 6 months post-baseline, significant differences in the PHQ-9 scores existed, with intervention participants expressing fewer depression-related symptoms than UC participants: 5.4 (SD=6.3) vs. 10.0 (SD=8.0) respectively (t= 2.67; p=0.009).

Conclusions and Implications: Findings suggest that telephone CBT is effective in reducing depression symptoms among rural Latino primary care patients. Also, they signal that telephone delivery was acceptable to Latinos and feasible in rural primary care. Study findings highlight the manualized intervention's potential to reduce disparities in depression care for rural Latinos in real world settings. Further research is warranted.