Significant mental health disparities exist for Hispanic populations, especially with regard to depression treatment. Low use of anti-depressant medication, poor provider-patient communication, and persistent stigma around depression are key barriers to treatment. We present findings from a randomized control trial of a culturally adapted depression education Fotonovela and subsequent measurement-based integrated care for the treatment of depression, which will help build the evidence around cultural adaptations in treatment to reduce mental health disparities.
We conducted a randomized controlled trial among 150 depressed adult Hispanics in a primary care safety net setting, testing the effectiveness of a culturally appropriate depression education intervention to reduce stigma and increase uptake in depression treatment among Hispanics, and implement a Measurement-Based Integrated Care (MBIC) model with collaborative, multi-disciplinary treatment and culturally tailored care management strategies. An intention-to-treat approach was used to analyze outcome data whereby the last available measurement was then used for all time points through the 12-month final follow-up.
At baseline, 98.0% of the sample reported moderate to severe depressive symptoms. The vast majority were women (n=133, 88.7%), Spanish speaking (n=136, 90.7%), and reported some high school or less education (n=79, 52.7%). Tests between the two groups on patient indicated randomization produced largely comparable groups on relevant patient characteristics and study measures. Results indicated that while depression scores significantly decreased over time for participants (F[2.811, 416.054]=197.689, p<.001, partial 𝜂2=.572), no differences between the Standard Education and Fotonovela groups were found (F[1, 148]=0.703, p=.403, partial 𝜂2=.005). For all participants at 12-month follow-up (n=125), 101 patients (80.8%) reported a 50% of greater reduction in depression scores from baseline, yet this reduction was not significantly associated with treatment group (𝜒2=2.321, df=1, p=.135, V=.134). Depression knowledge scores significantly differed over time (F[3.52, 517.99]=10.66, p<.001, partial 𝜂2=.080) and by intervention group (F[1, 147]=13.09, p<.001, partial 𝜂2=.082). Across all timepoints, the group receiving the Fotonovela was found to have significantly higher depression knowledge (Cohen’s d=.375 to .618) with the greatest difference observed directly after the educational visit (EV). One hundred and thirty-three participants (88.7%) engaged in treatment following the intervention: 62 participants (46.6%) received counseling only without antidepressant medication and 71 participants (53.4%) received counseling and antidepressant medications.
When treated in an integrated, multi-disciplinary model, low-income, uninsured, Spanish-speaking patients with depression in this primary care clinic experienced significant improvement in their depression. While there was no difference in treatment outcomes between patients receiving culturally adapted depression education compared to a traditional depression education pamphlet, patients who received the Fotonovela intervention demonstrated significantly greater knowledge of the disease immediately after the intervention which continued over time. Since Hispanics, in particular, are more likely to receive mental health care in primary care settings, results confirm decades of research demonstrating improved mental health when treated in an integrated model. The addition of unique culturally adapted tools show promise for improving disease literacy and could reduce disparities for populations who lack access to mental health specialists.