Cultural Adaptations of Psychosocial Interventions for Latinxs with Schizophrenia: A Systematic Review Using the Ecological Validity Framework to Identify Key Cultural Elements

Background and Purpose:

Latinxs with a diagnosis of schizophrenia experience compounded disparities in mental health service access, treatment quality, and functional outcomes. Underutilization of outpatient mental health services has been attributed in part to culturally discordant care. Fortunately, cultural adaptations of evidence-based interventions may offer equitable, appropriate, and effective treatment options. Recent studies find culturally adapted psychosocial interventions are more effective than usual treatments among Latinxs and individuals with schizophrenia. The current study is the first systematic review to focus on cultural adaptations for Latinxs with schizophrenia. The objectives are to (1) summarize cultural elements important to adapting interventions for use with Latinxs with schizophrenia, and (2) develop recommendations for continued research in culturally competent care for this group.

Methods:

Consistent with PRISMA guidelines for systematic reviews, a robust search string was used to identify articles that reported on culturally adapted psychosocial interventions for schizophrenia. For this review, “Latinx” was operationalized as having origins in Mexico, Central America, South America (excluding Brazil), and the Caribbean (i.e., Puerto Rico, Dominican Republic, and Cuba). Electronic databases included Medline, PsychINFO, ClincalTrials.gov, Cochrane Library, and LILACS. Only experimental studies were included in this review, in either English or Spanish, with no restrictions for date of publication. Systematic snowballing, hand searching, and consultations with field experts complemented the search. The review included analysis of cultural modifications using the Ecological Validity Framework, which is recommended for systematically documenting cultural adaptations.

Results

A total of eleven articles were identified, with eight studies conducted in the U.S. and three in Mexico. All studies were randomized controlled trials of psychosocial interventions for schizophrenia, including family psychoeducation, skills training, group therapy, and a comprehensive first-episode program. Positive outcomes reported were improved medication adherence, greater skill acquisition and generalization, lower rates of hospitalization, improved illness literacy, and lower levels of family burden compared to control conditions. Common cultural elements that were adapted across studies were culturally-relevant language translation and some level of family involvement. All studies also made efforts to incorporate culturally congruent mental health professionals in the delivery of interventions. In terms of content and context, most studies specifically modified elements from original intervention protocols or traditional service delivery locations to improve cultural relevance and feasibility. In some studies, therapeutic goals involved meeting the needs of the individual and the family unit. Seven studies included samples that were either Mexican or Mexican-American while others reported multiple Latinx subgroups.

Conclusions and Implications:

Cultural adaptations of psychosocial interventions for schizophrenia show promise toward reducing and eliminating mental health disparities by including family, using Spanish, incorporating spirituality/religiousness, and using Latinx icons, sayings, and activities as part of the treatment. Cultural adaptations are effective and feasible, but most research to date has been conducted using mostly Mexican-origin samples. While this is the largest Latinx subgroup in the U.S., scholars and practitioners should be cautioned in generalizing identified cultural elements to all Latinx groups. Future research recommendations include expanding samples to other Latinx subgroups, including a more comprehensive description of modified cultural elements.